London North West Healthcare NHS Trust Ealing Hospital Quality Report

Ealing Hospital Uxbridge Road Southall Middlesex Date of inspection visit: 19 - 23 October 2015; UB1 3HW unannounced inspections between 3 - 7 November Tel: 020 8967 5000 2015 Website: www.lnwh.nhs.uk Date of publication: 21/06/2016

This report describes our judgement of the quality of care at this hospital. It is based on a combination of what we found when we inspected, information from our ‘Intelligent Monitoring’ system, and information given to us from patients, the public and other organisations.

Ratings

Overall rating for this hospital Requires improvement –––

Urgent and emergency services Requires improvement –––

Medical care (including older people’s care) Requires improvement –––

Surgery Requires improvement –––

Critical care Good –––

Services for children and young people Requires improvement –––

End of life care Good –––

Outpatients and diagnostic imaging Good –––

1 Ealing Hospital Quality Report 21/06/2016 Summary of findings

Letter from the Chief Inspector of Hospitals

Ealing Hospital is part of London North West Healthcare NHS Trust, which is one of the largest integrated care trusts in the country, bringing together hospital and community services across Brent, Ealing and Harrow. Established on 1 October 2014 from the merger of North West London NHS Trust and Ealing Hospitals NHS Trust, and employing more than 8,000 staff it serves a diverse population of approximately 850,000. The trust runs Northwick Park Hospital, St Mark’s Hospital, Harrow; Central Middlesex Hospital in Park Royal and Ealing Hospital in Southall. It also runs 4 community hospitals – Clayponds Rehabilitation Hospital, Meadow House Hospital, Denham unit and Willesden Centre - in addition to providing community health services in the London Boroughs of Brent, Ealing and Harrow. At the end of the financial year 2014-15 the trust had a deficit of £55.9 million. We carried out this inspection as part of our comprehensive acute hospital inspection programme for combined acute hospital and community health based trusts. We inspected Northwick Park Hospital, Ealing Hospital and the following community health services: community services for adults; community services for children, young people and families; community inpatient services; community services for end of life care and community dental services. The announced part of the inspection took place between 19-23 October 2015 and there were further unannounced inspections which took place between 3-7 November 2015. Overall we rated this hospital as requires improvement. We rated critical care, end of life care and outpatients and diagnostic services as good. We rated the following acute services provided by the hospital as requires improvement: Urgent and emergency care, medical care including care of the elderly, surgery, and services for children. and end of life care. Our key findings were as follows: • The merger of the trust had been protracted and subject to delay. This had had a negative effect on performance and leadership. • We saw overall disappointing progress in merging systems and processes at the trust. To most intents and purposes Ealing and Northwick Park appeared to be operating as separate entities and community health services appeared disengaged from the rest of the trust. • There appeared to be substantial duplication of support functions at both main sites. There appeared to have been lack of control over spend of administrative, non-staff, and nursing staffing budgets with little rationale over nursing numbers on wards. • A new chief executive had recently been appointed earlier in 2015. She was in the process of building a new executive team and by the time of our inspection only one member of the previous substantive executive team was in post. This meant that the new executive team were in the process of getting to grips with their respective functions. • All staff working at the hospital were dedicated, caring and supportive of each other within their ward and locality. There was a high degree of anxiety and uncertainty borne out of the merger and also fears of service removal and potential job losses particularly at Ealing Hospital. • There appeared to be a lack of firm information provided to staff about the effects of Shaping a Healthier Future - to reconfigure services in north west London - despite the chief executive holding regular briefing session. This added to staff anxieties, particularly at Ealing. • We saw several areas of good practice or progress including: • a good service overall for end of life care particularly at Ealing and in the community health service. • caring attitudes, dedication and good multi-disciplinary teamwork of clinical staff.

2 Ealing Hospital Quality Report 21/06/2016 Summary of findings

• good partnership working between urgent and emergency care staff and London Ambulance staff. • good induction training for junior doctors. • research projects into falls bundles, stroke trials and good cross site working in research. • Staff told us there were good opportunities for training and career development. • We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. • The play specialists in services for children demonstrated how they could make a difference to the service and its environment in meeting the needs of the children and young people. This included an outstanding diversional therapy approach for children and young people, which was led by the play specialist and school tutor. • evidence of good antibiotic stewardship, particularly at Ealing pharmacy, with regular reviews of need; and the roll out of drug cabinets across certain parts of the trust with secure finger print access. • patient satisfaction data collected by iPAD by Ealing pharmacy. However, there were also areas of poor practice where the trust needs to make improvements including the following: • The performance dashboards for ED showed that compliance with achieving the mandatory targets, including the 4 hour treatment target, had been poor over the previous 12 months. Performance at Ealing had dropped since the merger. • The emergency department participated and performed poorly in the College of Emergency Medicine audits on pain relief, renal colic, fractured neck of femur and consultant sign-off; and there were no clear action plans drawn up by the department indicating what actions were taken as a result of the audits. • Compliance with safeguarding training was poor particularly among medical and dental staff. • The trust target was to have 95% of staff having completed mandatory training. Trust data, as of March 2014 – July 2015, showed compliance with the target was poor in many areas. • We saw examples of poor infection control practice such as linen left on a bin when a nurse was putting gloves on, staff wearing nose rings and hooped earrings that were not covered and name badges that were made of paper. • In surgery, several groups of patients had no formally defined pathway, which impacted on their safety. • The National Bowel Cancer Audit for 2014 indicated that data completeness for patients having major surgery was poor at 30%, compared with an England average of 87%. • There was a lack of formal escalation process for surgical patients who deteriorated on eHDU aside from the support provided by the outreach team. • Staff on wards outside of the end of life team had a poor understanding of end of life care and the trust LDLCA - Last days of life care agreement. Concern was raised that doctors and nurses on the wards did not recognise deteriorating and dying patients. • Signage for outpatient clinics was in some cases poor and or stopped short of providing clear directions for patients. • At Ealing ED we had some concerns around the care and treatment of children. There were insufficient children’s nurses employed to ensure they were consistently available at all times. Not all adult-trained staff had been trained in paediatric life support. • There were some aspects of poor morale of staff on the medical wards at Ealing. • There were some concerns with cleanliness and the state of repair or servicing of equipment and fixtures on medical wards at Ealing. • Audits showed hand hygiene was a concern with some wards either not submitting audits or scoring less than 90%. • We had concerns with medicines given by night staff. Drug rounds were arranged so night staff had a round at the start and two at the end of their shift with a potential increased risk of error. • All types of therapy visits on wards were unscheduled meaning patients could miss their therapy if they were away from their bed or in pain.

3 Ealing Hospital Quality Report 21/06/2016 Summary of findings

• We were concerned at the lack of provision for dementia care and inconsistent assessment of patients failing to direct them to a dementia friendly wards at Ealing. However, patients living with dementia were not specifically triaged to be admitted to this ward and some aspects of the ward were not dementia friendly. • In surgery at Ealing there was inadequate stock of some “bread and butter” items of equipment, such as endoscopic gastro-intestinal cartridges. Sets came back from the decontamination unit incomplete. • At Ealing OPD, the outpatients risk register identified five issues of concern including lack of capacity, temperature in the women’s clinic environment, lack of availability of complete medical records, overbooking clinics and absence of a dedicated plaster sink in the plaster room. • Trust wide there were temperature control issues across sites in rooms where medicines are stored. • The above list is not exhaustive and the trust should address these and the rest of the issues outlined in our reports in its action plan. Professor Sir Mike Richards Chief Inspector of Hospitals

4 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

Our judgements about each of the main services

Service Rating Why have we given this rating? Urgent and Requires improvement ––– The percentage of patients seen within 4 hours was emergency better than the England average before the merger services with the London North West Healthcare and has since fallen to worse than the England average and the 95% standard set by the Department of Health. It fell sharply in December 2014 to 81% and has since moved up to 90% from April 2015 but was still below the England average. We had some concerns around the care and treatment of children. There were insufficient children’s nurses employed to ensure they were consistently available at all times. Not all adult-trained staff had been trained in paediatric life support. The department had not performed well in national audits by the College of Emergency Medicine that measured performance against best practice and good clinical outcomes. Consultant sign-off, renal colic, fractured neck of femur, severe sepsis and septic shock were all areas of concern. We could see no clear plan of action to address this poor performance. Unplanned re-attendance rates (within 7 days) reduced in January 2014, but remained worse than the England average and the required standard from January 2013 – February 2015. We reviewed staff training records and noted that all staff had received mandatory training, including safeguarding adults and children. Mental capacity assessments were being undertaken appropriately and staff demonstrated knowledge around the trust’s policy and procedures with regards to mental capacity and deprivation of liberty safeguards. Staff took the time to listen to patients and explain to them what was wrong and any treatment required. Patients and relatives told us that they had all their questions answered and felt involved in making decisions about their care and treatment. Patients were treated with compassion and respect throughout their stay in the accident and emergency. Staff made sure patients were involved in discussions about their care and understood what was happening to them.

5 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

We found there was good clinical leadership and that staff continued to work well as a team and were motivated and positive about working for the department. Staff were well supported by clinical leads and local senior management. However the corporate leadership were not visible and less supportive of staff.

Medical Requires improvement ––– Medical services required improvement at EH in care safety, effectiveness, responsiveness and leadership. (including We were particularly concerned about the older sustainability of already stretched staffing levels people’s when a new ward will be opened at Northwick Park which some recently appointed staff will be care) allocated to. Patient records were not complete or patient focused in a number of instances. There was some over reliance on junior staff and there was a lack of cross site governance and working. Discharges were constantly delayed and patients were not always cared for on the correct ward. There was a lack of support and communication from divisional level. However we found caring was good overall with positive patient feedback and improving friends and family test scores. Incidents were mostly learnt from although only if they occurred locally. There was awareness of the Mental Capacity Act and pain relief was well managed. There was good patient flow through the AMU and complaints were learnt from. There was support from local leadership and some performance oversight.

Surgery Requires improvement ––– Patient safety checks in the Endoscopy department were not taking place using the World Health Organization (WHO) Surgical Safety Checklist. In addition the arrangements related to surgical instrumentation and availability of technical equipment was not always optimised. Staff had a good knowledge of the issues around capacity and consent but there was lack of assurance that staff had received Mental Capacity or Deprivation of Liberty Safeguard training.

6 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

The surgical risk register did not always identify the specific location the risk related to and dates for resolution of risks had not always been stated. The recovery area within theatres was not able to cope with the level of activity. Furthermore, the area used by children had not been designed or planned to take into account their needs. Referral to treatment times were not being met in some surgical specialties. Theatres were not always effectively utilised and operating sessions started and finished later than planned, which impacted on patient discharges. Staff reported positively on their immediate line managers and demonstrated a commitment to the delivery of high quality patient care. Despite this, staff had been affected by recent changes following the merger of locations and were struggling to understand the future direction of the service at the location. The environment in surgical services had not been developed to address the needs of individuals living with dementia. Where complaints were raised, these were investigated and responded to and where improvements were identified, these were communicated to staff. The governance arrangements facilitated the monitoring of risks, safety, patient outcomes and effectiveness of the service and information was communicated across all levels.

Critical care Good ––– Overall the critical care at Ealing was good. Patients were cared for by a safe number of competent staff who used evidence-based practice to achieve good outcomes. Staff had good access to patient information and current best practice guidelines as well as up to date research articles. Patient safety thermometer results were good and there was a proactive incident reporting culture. We saw evidence that incidents were investigated appropriately, with learning points disseminated to unit staff,. hHowever, there was limited shared learning relating to incidents. The vision for the service focused on an improvement in quality and safety through investment in staff training and development.

7 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

We saw some evidence of innovation such as the development of the high flow oxygen service. The critical care service was caring and patient privacy and dignity was maintained at all times. Staff knowledge and implementation of safeguarding was good and we saw evidence that regular patient risk assessments took place. Patients’ pain was frequently assessed and well managed by staff who ensured patient comfort at all times. Multidisciplinary working was embedded on the unit, particularly during the weekly meeting.

Services for Requires improvement ––– Children and young people’s services overall children requires improvement but the service is considered and young good for caring. We found out of date policies still in people use, Control of Substances Hazardous to Health (COSHH) assessments not completed and chemicals found stored in an unlocked cupboard in an unlocked cleaning room in the children’s ward. There were notable staff shortages in some areas with a high use of agency or bank staff covering for sickness and additional leave. Senior staff had to seek out patients when children were admitted to an adult bed, as there was no flagging system. There were gaps in support arrangements for children with long term conditions e.g. epilepsy and no identified nurse specialist to support this group of patients. The service was not responsive to meeting the needs of children and young people when in the children’s accident and emergency department as the waiting time was reported as too long by parents seen. The children’s waiting times data was requested from the trust but not received. We were informed of the future change for the service which had been developed. Eight staff were spoken to by the inspectors of which two staff members were not aware of the local or trust strategy. The arrangements for governance and performance management did not always work effectively as items on the risk register did not reflect all the areas that require improvement. Leadership within the service was rated as requiring improvement. Staff informed us that managers had not always been visible on this site since the movement of managers to the Northwick Park site.

8 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

End of life Good ––– We found the specialist palliative care team (SPCT) care to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. However there were some concerns raised by specialist staff and from our observations about whether all generalist nurses, doctors and consultants had the expertise to recognise patients who were dying. The knowledge base was described as “patchy” especially since the withdrawal of EOL and specialist palliative care induction training which had given all staff a base knowledge and understanding. We were given examples of patients’ treatment and observations continuing when EOL had been identified. This could cause the patient unnecessary pain and discomfort at a time when these actions would make no difference to the patient’s health and wellbeing. The Last Days of Life Care Agreement which replaced the Liverpool Care Pathway was not being used for any of the patients we reviewed, although ‘do not attempt cardio pulmonary resuscitation’ orders were in place. The completion of DNACPRs was variable. Some were not fully completed or discussed or signed off by a senior clinician. The SPCT leads were focussed on raising staff awareness around EOLC. However they felt this should be more widely embraced in the trust. Staff were aware of their responsibility in raising concerns and reporting incidents. However, we found there was apathy in reporting everything including near misses due to a lack of feedback and learning outcomes. The SPCT at Ealing hospital did not feel engaged with the trust strategy and were unsure how it would affect services at Ealing Hospital.Although the lead for palliative and cancer services visited Ealing Hospital twice a week there was little local leadership on a day-to-day basis.

Outpatients Good ––– Overall outpatient and diagnostic services at Ealing and Hospital were good because there were systems in diagnostic place to identify record and review incidents and imaging staff were aware of how incidents should be escalated and recorded.

9 Ealing Hospital Quality Report 21/06/2016 Summar y of findings

Summary of findings

Outpatient and diagnostic services were visibly clean and there were processes to ensure cleaning was maintained. We saw good evidence of how the diagnostic services benchmark their services through national and local audit activity and national guidelines including NICE and Royal College of Radiologists. We found staff were compassionate, caring and proud to work at Ealing Hospital. Mandatory training was provided however staff told us face to face training was often difficult to access or attend due to clinical commitments. Hard copy records were not always available in time for clinics; the trust was aware of this and had started phased plans to integrate hard copy records in preparation for a move to an electronic record management system across all sites. The service had a backlog of patients waiting more than 18 weeks for an appointment and had attempted to reduce waiting times for patients. There was a good system in place which highlighted the patients who had waited longest and should be clinically prioritised for the first available appointments.

10 Ealing Hospital Quality Report 21/06/2016 Ealing Hospital Detailed findings

Services we looked at Urgent and emergency services; Medical care (including older people’s care); Surgery; Specialist burns and plastic services; Critical care; Services for children and young people; End of life care; Outpatients and diagnostic imaging

11 Ealing Hospital Quality Report 21/06/2016 Detailed findings

Contents

Detailed findings from this inspection Page Background to Ealing Hospital 12 Our inspection team 13 How we carried out this inspection 13 Facts and data about Ealing Hospital 13 Our ratings for this hospital 14 Findings by main service 16 Action we have told the provider to take 135

Background to Ealing Hospital

Ealing Hospital is part of London North West Healthcare Services provided: NHS Trust is one of the largest integrated care trusts in Ealing Hospital provides the following inpatient services: the country, bringing together hospital and community general surgery, trauma and orthopaedics, cardiology, services across Brent, Ealing and Harrow. Established on gastroenterology, respiratory medicine, infectious 1 October 2014 from the merger of North West London diseases, general medicine, urgent and emergency care, NHS Trust and Ealing Hospitals NHS Trust, and employing critical care, paediatrics, cardiology and obstetrics. more than 8,000 staff it serves a diverse population of approximately 850,000. The hospital provides the following outpatient services: anticoagulant services, audiology, breast care, care of the The trust runs Northwick Park Hospital, St Mark’s elderly, chest pain, chiropody, clinical haematology, Hospital, Harrow; Central Middlesex Hospital in Park clinical oncology, colposcopy, dermatology, diabetic Royal and Ealing Hospital in Southall. It also runs 4 medicine, dietetics, dressings, endocrinology, ear nose community hospitals – Clayponds Rehabilitation and throat medicine (ENT), gastroenterology, general Hospital, Meadow House Hospital, Denham unit and medicine, general surgery, gynaecology, infectious Willesden Centre - in addition to providing community diseases treatment, maternity scans, neurology, health services in the London Boroughs of Brent, Ealing obstetrics, oral surgery, paediatric cardiology, paediatrics, and Harrow. phlebotomy, renal medicine, respiratory medicine, At the end of the financial year 2014-15 the trust had a rheumatology, surgical appliances, trauma and deficit of £55.9 million. orthopaedics, urology and vascular surgery. The trust currently does not have foundation trust status. Beds and staff employed: The hospital has 358 beds and employs approximately 1620 staff. Ealing Hospital serves an ethnically diverse population mainly in the London Borough of Ealing. The health of There were 102,227 A&E attendances at Ealing Hospital in people in Ealing is varied compared with the England 2014/15 and 22,012 inpatient admissions in 2014. average. Deprivation is higher than average and about Between April 2014 and March 2015 there were 216,448 21.6% (15,300) children live in poverty. It ranks 80th most outpatient appointments. deprived of 326 local authorities in the country. Life There were 48 cases of C.Diff, 5 cases of MRSA and 25 expectancy for both men and women is higher than the cases of MSSA in this Hospital between August 2014 and England average in the London Borough of Ealing. July 2015.

12 Ealing Hospital Quality Report 21/06/2016 Detailed findings

Between August 2014 and July 2015 there was one never Between April 2013 and March 2014, the trust received event at this location, and 148 serious incidents. 223 complaints relating to Ealing Hospital.

Our inspection team

Our inspection team was led by: of life care nurse, maternity doctor, midwife, general medicine doctor, general medicine nurse, outpatients Chair: Dr Richard Quirk, Medical Director Sussex doctor, outpatients nurse, paediatric doctor, paediatric Community NHS Trust. nurse, surgery doctor, adult community nurse, Head of Hospital Inspection: Robert Throw and Nicola community midwife, chiropodist/podiatrist, adult Wise ( observing) CQC. community doctor, adult physiotherapist, surgery nurse, occupational therapist, junior doctor, student nurse, The inspection team consisted of CQC managers and community children's nurse, sexual health therapist, inspectors plus specialist clinical and non-clinical experts by experience/patient representatives. advisers including: senior NHS manager, A&E doctor, A&E nurse, critical care doctor, child safeguarding nurse, end

How we carried out this inspection

To get to the heart of patients' experience of care in this We held a public listening event with the intention of acute hospital and community health setting we always listening to the views of patients, their families and carers as the following five questions of every service and as well as members of the public about the services provider: provided by the trust. • Is it safe? We spoke with patients and their families and carers and • Is it effective? members of staff from all the ward and community health • Is it responsive to people's needs? areas. We reviewed records of personal care and • Is it well-led? treatment as well as trust policies and guidelines. We held focus groups of different clinical and non-clinical Prior to the announced inspection, we reviewed a range staff grades to gain their views. Similarly we held a focus of information we held and asked other organisations to group for black and ethnic minority staff. share what they knew about the trust. These included local clinical commissioning groups, NHS England, Health In addition to the announced inspection which took Education England, NHS Trust Development Authority place between 19 - 23 October 2015, we carried out (now NHS improvement), General Medical Council, the unannounced visits between 3 - 7 November 2015. Nursing and Midwifery Council, Royal Colleges and local Healthwatch.

Facts and data about Ealing Hospital

Safe • Infection rates for C. diff and MSSA have been higher since the trust merger. MRSA rates were variable between • Serious incidents: 148 were reported for Ealing 0 and 2 in any given month with no discernible trends. between Aug 2014 and Jul 2015. • At Ealing the proportion of junior doctors is higher and the proportion of consultants is lower than the England average.

13 Ealing Hospital Quality Report 21/06/2016 Detailed findings

• There were four never events reported between August In the Cancer Patient Experience Survey the Trust was in 2014 and July 2015. 3 in Northwick Park(Medicine x2 and the bottom 20% of trusts for 16 out of 34 indicators. Surgery x1). There was also one in Ealing in the Children’s Patient Led Assessments of the Care Environment: There core service. when an eight-week-old baby was given an was a mixed performance compared with the England oral dose of antibiotic intravenously. average for all four measures. There was an elevated risk NRLS incidents: There were fewer NRLS incidents per 100 for food (Jan to Jun 14) in CQC's Hospital Intelligent admissions than the England average for the same Monitoring (IM) report May 2015. This appeared to relate period. to Ealing, where 2014 Privacy, dignity and wellbeing score had also fallen). Bank and agency staff levels are more than double the England average. The hospital and trust scored "about the same" as other trusts in 7 and were in the "worst performing trusts" in 5 The CQC intelligence monitoring report for May 2015 indicators in the 2014 in-patient survey. showed elevated risks for: Responsive - Nursing staff (low) in proportion to occupied beds (Jan to Dec 14) In CQC's Hospital Intelligent Monitoring report for May 2015, the hospital and trust flagged as an elevated risk - Other clinical staff (low) in proportion to occupied beds indicator for A&E waiting times more than 4 hours (Oct to (Jan to Dec 14). Dec 14). Effective: Well-led Despite a rise in HSMR mortality, the CQC Hospital IM The sickness absence rates at Ealing have been report May 2015 showed no evidence of elevated risk. consistently below the England average. Caring: There was mixed performance in the NHS Staff Survey Prior to the merger both former trusts’ performance in 2015, with 4 positive and 7 negative findings. 19 findings the Friends and Family Test was consistently below the were within expectation for a hospital of this size. England average. It has subsequently improved to a level above the England Average.

Our ratings for this hospital

Our ratings for this hospital are:

14 Ealing Hospital Quality Report 21/06/2016 Detailed findings

Safe Effective Caring Responsive Well-led Overall

Urgent and emergency Requires Requires Requires Requires Requires Good services improvement improvement improvement improvement improvement Requires Requires Requires Requires Requires Medical care Good improvement improvement improvement improvement improvement Requires Requires Requires Requires Surgery Good Good improvement improvement improvement improvement Requires Critical care Good Good Good Good Good improvement Services for children Requires Requires Requires Good Good Good and young people improvement improvement improvement Requires End of life care Good Good Good Good Good improvement Outpatients and Good N/A Good Good Good Good diagnostic imaging

Requires Requires Requires Requires Requires Overall Good improvement improvement improvement improvement improvement

Notes

15 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the service Summary of findings The emergency department (ED) at Ealing hospital (EH) is The emergency department at Ealing Hospital (EH) open 24 hours a day, seven days a week. It treats people required improvement to ensure that services were safe with serious and life-threatening emergencies and those and responsive to the needs of the patients being with minor injuries that need prompt treatment. The treated at the hospital. department consists of separate areas including: majors, minors, resuscitation areas, an ambulatory unit, and a The percentage of patients seen within 4 hours was clinical decision unit (CDU). In addition, there is a separate better than the England average before the merger with paediatric area for children and young people under the the London North West Healthcare and has since fallen age of 16. The resuscitation area has four beds one of to worse than the England average and the 95% which is primarily for children. standard set by the Department of Health. It fell sharply in December 2014 to 81% and has since moved up to Ambulance patients who are unwell and may need 90% from April 2015 but was still below the England admission are assessed and directed through to the majors average. The percentage of patients waiting four to 12 or minors area depending on their clinical needs. The hours before being admitted was better than the ambulatory emergency care unit operates from 9am to England average before the merger in October 2014. 6pm, Monday to Friday. This service provides same-day emergency care for patients who were able to be assessed We had some concerns around the care and treatment and treated without the need for an overnight admission. of children. There were insufficient children’s nurses The emergency department sees approximately 53,270 employed to ensure they were consistently available at patients a year, of which approximately 18% are children. all times. Not all adult-trained staff had been trained in paediatric life support. We visited the service over two days and observed care and treatment and looked at 18 treatment records. During our The department had not performed well in national inspection, we spoke with 12 members of staff, including audits by the College of Emergency Medicine that nurses, consultants, doctors, receptionists, managers, measured performance against best practice and good support staff and ambulance crews. We spoke with five clinical outcomes. Consultant sign-off, renal colic, patients and two relatives. We received comments at our fractured neck of femur, severe sepsis and septic shock listening event and from people who contacted us to tell us were all areas of concern. We could see no clear plan of about their experiences, and we reviewed performance action to address this poor performance. information about the trust.

16 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

Unplanned re-attendance rates (within 7 days) reduced Are urgent and emergency services safe? in January 2014, but remained worse than the England average and the required standard from January 2013 – Requires improvement ––– February 2015.

We reviewed staff training records and noted that all Incidents were reported promptly and investigated staff had received mandatory training, including appropriately. However, we were concerned that lessons safeguarding adults and children. Mental capacity learnt were not always fully embedded into practice. We assessments were being undertaken appropriately and noted that some incidents such as catheter related urinary staff demonstrated knowledge around the trust’s policy tract infections (CUTI)’s and pressure ulcers were not and procedures with regards to mental capacity and routinely reported. This is indicative of a risk that incidents deprivation of liberty safeguards. may not be formally reported by the staff. Staff took the time to listen to patients and explain to The supply of suitable monitoring equipment was them what was wrong and any treatment required. insufficient within the department. Patients and relatives told us that they had all their questions answered and reported being involved in There was a high use of agency nurses and locum doctors making decisions about their care and treatment. within the department. Most of the temporary staff Patients were treated with compassion and respect members were unfamiliar with the department, or the throughout their stay in the accident and emergency. policies and procedures they should work to. We found Staff made sure patients were involved in discussions that patients did not always receive emergency care about their care and understood what was happening promptly which could have impacted on their clinical to them. condition and outcome. We found there was good clinical leadership and that Children had appropriate separate facilities within the staff continued to work well as a team and were department. Safeguarding was understood and protocols motivated and positive about working for the were followed when required. Staff were aware of the department. Staff were well supported by clinical leads challenges within the department regarding children’s and local senior management. However the corporate service provision, and were working towards addressing leadership were not visible and less supportive of staff. those challenges with training and recruitment. However, we had some concerns around the care and treatment of children. There were insufficient children’s nurses employed to ensure they were consistently availability at all times. Not all adult-trained staff had received training in paediatric life support. The department did not have enough doctors and nurses to keep patients safe at all times. Medicines and records were appropriately managed and infection control procedures were followed. Incidents • There was one never event regarding a medicine error in the children’s area of the department recorded between April 2014 and July 2015. A child was given an oral medicine through an intravenous route. We saw evidence in the form of an investigation report that the incident was investigated using root cause analysis and lessons learnt were shared with staff at the department.

17 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

The investigation followed a proper root cause analysis • Adequate hand washing facilities and alcohol gel were process with regards to the background of the incident, available throughout the department. We observed medical history of the patient and chronology of what infection control practices, such as staff following hand happened with identification of contributory factors, hygiene practices, ‘bare below the elbow’ guidance, and root causes and recommendations. Senior nursing staff wearing personal protective equipment such as gloves we spoke with confirmed that, they were provided with and aprons as appropriate. information about the incident. • Equipment, including patient trolleys, were clean and • Nursing staff we spoke with told us they knew how to cubicles were cleaned and labelled as been cleaned. report an incident using the Datix Incident Reporting Cleaning staff we spoke with confirmed that there was System. They said they had reported incidents an escalation process in place when extra cleaning staff frequently and had received feedback on the incidents were required. they had reported. Environment and equipment • The department had not reported any pressure ulcers, • The supply of suitable monitoring equipment was falls with harm or catheter related urinary tract insufficient within the department. We noted that only infections (CUTI’s) between June 2014 and June 2015. one monitored bed was available. This meant patients However, some nurses we spoke with told us they had might not be able to be monitored in time when needed frequently reported pressure ulcers and UTI’s, which had and unable to receive safe care and treatment when the not been recorded formally by the department. monitored bed is occupied. • We were told that learning from incidents and ‘near • We found that regular checks had been completed on misses’ were shared with staff via emails and team days. key equipment, such as echocardiogram However, we did not see any evidence to support this (ECG)machines, to ensure that they were working. and most of the staff we spoke with were not able to • We checked the resuscitation trolleys and found them to show us any emails as such. There was some be correctly stocked and maintained. They were information about the department and teaching appropriately checked at each shift change with records programs clearly displayed on a noticeboard in the staff kept to show the checks took place. room. • There was a safe and effective system in place for the • We noted that managers and senior staff had a good repair and maintenance of equipment. The staff were understanding of Duty of Candour and had attended aware of the process for obtaining medical equipment relevant training about their responsibilities in and what to do where the equipment was found to be in disclosing to patients when an incident that could cause need of repairs. harm had occurred. • We found potential ligature points in the mental health Cleanliness, infection control and hygiene place of safety room in Ealing ED and brought this to the attention of the nurse in charge who immediately • The department was clean and staff were aware of the contacted the estates department to investigate. We current infection prevention and control guidelines. We have asked the trust to review all of the equivalent observed support staff cleaning the department facilities at its remaining locations including those we throughout the day. did not inspect on this occasion. • We looked at the department’s hand hygiene audit results and saw it had achieved 93% compliance from Medicines April 2015 to date. • Medicines were stored, managed, administered and • Sluices were clean and well organised, and clinical recorded safely and appropriately. Training data for the waste was handled and disposed of safely. Audits department showed that nursing staff had received showed hand hygiene scored over 95%. All the staff training in medicines management. observed appropriate infection prevention and control guidelines such as bear below the elbow, wearing personal protective equipment and washing hands between patient interactions.

18 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

• Nursing staff recorded fridge temperatures daily in all adult safeguarding and 79% had completed children’s the areas of the ED we visited. We did not find evidence safeguarding level two and 60% had completed level that the fridge was operated with temperatures out of three training against the trust target of 95%. We were the expected range. not told of any specific plans to increase this at the time • We checked medicine records and stocks of medicine, of our inspection. including controlled drugs. We found these to be • Staff that we spoke with were aware of their correct, detailing appropriate daily checks been carried responsibilities to protect vulnerable adults and out by qualified staff as required. children. They understood the safeguarding procedures • During the inspection, we looked at 18 sets of patients that were in place and how to report concerns. We did notes and, in particular, drug prescription charts. We not see any safeguarding referrals made during our found all drug prescription charts fully completed, with inspection. appropriate doctor’s signature. Mandatory training • We looked at patient prescription charts, which were • Mandatory training included essential topics such as fire completed and signed by the prescriber and by the training, health and safety, infection control basic life nurse administering the medicine. support and manual handling. We examined the Records training records for the department and found 85% of staff were up to date with their mandatory training. • The department had its own patient assessment record, • Mandatory training was provided in different formats, which included the patient’s personal details, previous including face-to-face classroom training and e-learning admissions, alerts for allergies, patient’s weight and (e-learning is electronic learning via a computer observations charts. system), although staff told us that there was limited • Patient records were a mixture of electronic and paper time allowed to complete e-learning. This meant that record.The completion of paper records was done with a sometimes they had to complete the e-learning in their variable degree of completeness. We reviewed 18 own time. patients’ records, and some of the issues uncovered • We were told that the target uptake for each mandatory were lack of pressure area assessments, and no training topic was different and this sometimes led to documented evidence of patients being seen within an confusion when assessing the completion of individual hour. However, all of them were signed and dated by mandatory training against trust targets. We did not see both medical and nursing staff. evidence of mandatory training provided for and • Medical and nursing records were kept together in a completed by agency staff including induction training. single set of patient notes, which were kept securely in a trolley by the nursing station. We found that, in the Assessing and responding to patient risk records we reviewed, initial clinical observations, such • The department operated a triage system of patients as blood pressure, pulse, respiration and temperature presenting to the department either by themselves or checks were recorded on all patients who attended the via ambulance. These patients were seen in priority department. order depending on their condition. During our Safeguarding inspection, we tracked a small sample of patients and found that they were seen by a clinician within 15 • Staff we spoke with had a good understanding of minutes of arrival into the department. safeguarding concerns for adults and children. Access to • Patients who walked into the department or who were information on how to report a concern was available brought by friends or family were directed to a and displayed on boards in the department. receptionist. Once initial details had been taken, the • All staff (including administrative staff) were expected patients were then assessed by a triage nurse to to complete level two child protection training and determine where the patient was to be sent for further senior clinical staff were expected to complete level treatment. If a patient was identified as needing urgent three training. At the time of our inspection, 84% of ED and more intensive intervention, they were transferred staff had completed mandatory training in level two

19 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

through to the majors or resuscitation area where They were supported by a health care assistant (HCA) at appropriate care and treatment was provided. Patients all times. Royal College of Nursing guidance states that requiring non-urgent care were signposted to the urgent the department should have two paediatric nurses on care centre operated by a different provider. duty at all times. Staff told us that sometimes they could • Patients arriving as a priority blue light call were not get a paediatric nurse so they would use adult ED transferred immediately through to the resuscitation nurses who had some experience in paediatrics. area. Such calls were phoned through in advance by the • Nursing staff told us that when a child attended the London Ambulance crew, so that an appropriate team department, appropriate staff from the children’s ward were alerted and prepared for the patient’s arrival. would attend if there was no paediatric nurse in the • We found that the department used a recognised department. national early warning score (NEWS) to assess patients • An ED education facilitator, who also worked clinically, and identify if their condition was deteriorating. Staff we supported nursing staff at the ED. This role coordinated spoke with were aware of the process and made the activities of nurses within the department and frequent records of patients’ vital signs. We examined 18 helped to develop competency assessments for nursing sets of notes and found that all of them had staff. appropriately completed NEWS monitoring forms. • Medical staffing • Doctors we spoke with told us that they were • The department employed 28 WTE medical staff, 17% of appropriately called by nursing staff to see deteriorating which were consultants, 53% were registrars, 4% were patients as necessary. middle grade and 25% junior grade doctors. The • Staff knew how to escalate key risks that could impact department had 25% medical staffing vacancy rate and on patient safety, such as staffing and bed capacity relied heavily on the use of locum medical staff. issues. There was an escalation policy in place and daily • The department had a lower percentage of consultants, involvement by bed managers and the matron to registrar’s and middle grade doctors, when compared to address capacity issues that impacted on patient care. the England average, and had a similar percentage to the England average of junior doctors. Consultant cover Nursing staffing was below College of Emergency Medicine • Evidence provided by the trust indicated that the recommendations and was listed on the trust risk department was not operating at the required whole register as insufficient to provide 24 hour cover resulting time equivalent posts (WTE) for nursing staff, with over in a reduced consultant led service. The mitigation a 37% vacancy rate as of August 2015. The vacancies action plan was to continue a consultant recruitment were filled using bank and agency staff. We did not see campaign. evidence that the department, at the time of our • Middle and junior grade doctors were on duty 24 hours a inspection, was using a recognised acuity or staffing tool day in the department. We spoke with junior and middle to determine its establishment of nursing posts. grade doctors who spoke positively about working in • We did not see evidence that staff shortages were the department. They told us that in-house teaching escalated on a day to day risk basis. However we were was well organised and comprehensive and their told by the matron that two new band five nurses were consultants were supportive and approachable. recently recruited and had since started working in the • A consultant was present in the department from 8am department. The service was also in the process of until 10pm Monday to Friday. There were middle-grade recruiting additional band six and band seven nurses to doctors and junior doctors overnight with a consultant support the workforce of the department. on site from 8am to 11am at the weekend plus an • Band seven staff nurses were usually in charge of the on-call consultant system during the rest of department and were usually supported by the matron the weekend and out of hours. who was on duty Monday – Friday from 9am – 5pm. • We saw consultants working in the department, and • The children’s ED operated three shift patterns (early, observed positive interactions between the consultants late and night). Only one paediatric qualified nurse was rostered on duty at any given time in the children’s ED.

20 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

and other clinical staff working in the department. The Emergency Medicine, the National Institute for Health and consultants were included in the team handovers with Care Excellence (NICE) and the Resuscitation Council UK, the nurses and junior doctors to ensure the consultant however some of the paper based policies in the in charge was aware of each patient in the department. resuscitation department folders we saw were out of date. • The department consistently relied on locum middle There was some evidence of adherence to national grade doctors. When we reviewed the rota, we noted guidance to provide evidence-based care and treatment for that the same doctors were consistently in use. patients. Patients were triaged as they entered the Major incident awareness and training emergency department. • The trust had a documented major incident and Departmental records showed that nearly all nursing staff business continuity plan, which listed key risks that had received appraisals. Staff were well supported, with could affect the provision of care and treatment. The good access to training, supervision and development. We major incident plan provided clinical guidance and saw effective collaboration and communication among all support to staff on treating patients of all age groups members of the multidisciplinary team and services were and included information on the triaging and geared to run seven days a week. management of patients suffering a range of injuries, Clinical audit activity was stronger in the department including those caused by burns or blasts and chemical because a consultant had been able to take specific contamination. responsibility for assessing the effectiveness of treatment • Guidance for staff in the event of a major incident was delivered in the emergency department (ED). available within the trust’s major incident plan, which was also located in the department. Evidence-based care and treatment • The department used a combination of National • Staff in the ED were well briefed and prepared for a Institute of Health and Care Excellence (NICE) and major incident and could describe the processes and College of Emergency Medicine (CEM) guidelines for triggers for escalation. Similarly, they described the patients care. Guidance was regularly discussed at arrangements to deal with casualties contaminated with governance meetings, disseminated to staff during team chemical, biological or radiological material or days. hazardous materials and items. • A range of clinical care pathways had been developed in accordance with recognised guidance for example, Are urgent and emergency services stroke, pneumonia, fractured neck of femur sepsis, renal effective? colic and head injury. The department audited (for example, treatment is effective) compliance with these pathways regularly. Ambulatory care pathways were also in place and followed by staff. Requires improvement ––– • The patient clinical assessment record reflected evidence-based guidance for effective risk assessment and included tools for assessing patient risks such as The department participated in the College of Emergency sepsis so that if the patient’s condition Medicine (CEM) audits; however there were no clear action deteriorated, medical staff could be alerted quickly. plans to indicate the improvements needed as a result of • A consultant within the department took the role of the audits were acted upon. Pain relief was offered audit lead. Junior doctors participated in departmental appropriately in most cases, and its effectiveness was audit activity. The next planned audit was in pain assessed and acted upon as shown by the CEM audits. management in ED in adults and children (as two Policies and procedures were developed in line with the separate audits) to be started in January 2016. The national guidance and best practice evidence from results and actions arising from the audits were professional bodies such as the Royal College of presented in the clinical governance committee meetings, which was held monthly at the trust.

21 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

• The hospital did not have specialist doctors for key Patient outcomes areas such as maternity, obstetrics and gynaecology • The department participated in national College of due to the closure of the maternity unit. This meant Emergency Medicine (CEM) audits so that they could doctors working in ED had to deal with these conditions benchmark their practice and performance against best themselves rather than being able to ask a specialist practice in other emergency departments. The CEM doctor to attend the patient. Doctors we spoke with told audits included consultant sign off, renal colic, fractured us that in exceptional circumstances, they could seek neck of femur and severe sepsis and septic shock. assistance from their colleagues in Northwick Park • The majority of the CEM audit results were worse than Hospital. There were no pathway or treating criteria for the national average, such as consultant sign-off. The the patients. Patients were stabilised and either sent standard states that three types of patients groups home with an appointment at the Northwick Park should be reviewed by a consultant prior to discharge. Hospital or a GP follow up appointment. These were adults with non-traumatic chest pain, febrile Pain relief children less than one year old and patients making an unscheduled return to the ED with the same condition • We spoke with 17 patients and some of them had been within 72 hours of discharge. The department in pain during their attendance. They all told us that performed worse than the UK average in all the eight they had been given pain relief very soon after arriving measures as they achieved an average of 2% against the at the hospital. Staff we spoke with were aware of the UK average of 14%. appropriate guidance on providing pain relief to • In the Renal Colic audit by the College of Emergency patients. Medicine in 2013, the target was that 98% of patients in • Pain assessment charts were used for recording severe pain should be provided with analgesia within feedback from patients on the level of their pain. We one hour of arrival in ED. The department achieved 65%. examined 18 sets of patient notes and in only one of This meant that 33% of the patients did not received them we found that a pain chart had not been analgesia within one hour of their arrival in the completed. department. • The department had participated in the national • The unplanned re-attendance rate to A&E was College of Emergency Medicine (CEM) audit in 2013 – consistently worse than the 5% target and the England 2014 for renal colic and fractured neck of femur, which average from January 2013 – February 2015.The average assessed patient’s experience of pain relief. The audits score for the department was 13%. This was an showed areas for improvement in consultant sign-off, indication that patients were possibly being discharged fractured neck of femur, renal colic and sepsis. However, inappropriately by the department. the hospital had not developed an action plan to • We looked at audit results and saw that they had not address the findings of the CEM audits. been reviewed by managers and priorities for Nutrition and hydration improvement had not been identified. Most of the • The department undertook regular food and drink clinical staff we spoke with were not aware of these rounds 24 hours a day, seven days a week. Patients had audits or the department’s results of the audit. We could also been provided with soup. However, we noted that not see any evidence that the results of the audit had patients were not being provided with hot food due to been used to improve the effectiveness of care. There recent changes of catering contract. The new catering was a lack of action plans which addressed the findings team had decided that it was against Health and Safety of audits in order to improve services. legislation to provide hot food from the existing kitchen. Competent staff A business case was made by the department to • The department was not compliant with nursing and upgrade the existing kitchen to be compliant with the clinical staffing guidance published by The health and safety legislation and the business case was Intercollegiate Standards for Children and Young People declined by trust management. Patients who were in Emergency Care Settings. This required nurses unable to eat or drink were prescribed intravenous working in the children’s ED to have a minimum level of infusion.

22 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

knowledge, skills and competence in both emergency • The percentage of nursing staff with completed nursing skills for the care of children and young people appraisals in the department was approximately 91% For example, they had not been trained in recognition of for the year which nearly met the trust’s ambitious target serious illness and identification of vulnerable patients of 95%. at the time of the inspection. Some of these nurses • The nursing and medical staff we spoke with were mostly worked on their own without the supervision of positive about ‘on-the-job’ learning and development the registered children’s nurse. opportunities. Medical staff told us clinical supervision • The children's ED had four paediatric nurses in post, and was in place and was non-hierarchical whereby staff only three were in active service, and the other one was could choose their own supervisors. on maternity leave. There was only one paediatric nurse • We were told that that staff had to undertake corporate on duty at any given shift at the department. induction. However, we saw staff who had started about • Not all the paediatric nurses had received training in few weeks previous to our inspection and they had not Advanced Paediatric Life Support, and there was no yet received their corporate induction. guarantee that the paediatric nurse on duty had this level of training. This created a potential risk to children Multidisciplinary working in the event of an emergency. • There was a mixed relationship between the paediatric • We saw evidence of development programmes for department and the local Child and Adolescent Mental different grades of nurses. There were two new band five Health Service (CAMHS) team who were sometimes staff nurses and they all worked as supernumerary unable to conduct an assessment. We were told that in members of staff for a designated period of time. most cases the CAHMS team did not see children within During this supernumerary period they had to have the stipulated timeframe as stated in the trust protocol. specific competencies signed off by a senior nurse • However we did see that the ED worked closely with the before being able to care for ED patients independently. Psychiatric Liaison Team, and they could be contacted They showed us evidence of their competency training. easily via bleep or the switchboard when needed. • Medical and nursing staff we spoke with told us they • There was a clear, professional and joint working were well supported with weekly training sessions. The relationship between the department and other allied department had a nurse educator who provided training healthcare professionals within other departments, and support to staff. Staff were positive about the input such as radiology, surgery, medicine and physiotherapy. of the nurse educator and found their role very good. • Medical and nursing staff we spoke with said there was However we didn’t see any evidence of the training they good multidisciplinary working and support. They said provided to staff. that multidisciplinary team meetings ensured good • Newly qualified nurses we spoke with had assessments communication and input of each professional in the to check their competency in key areas of staff nurse’s care of individual patients. We observed good role including ED competencies such as drug communication between different professionals and a administration, drug calculations, and setting up of respect for each other’s expertise and input. intravenous infusion. All nursing staff were required to Seven-day services undertake medicines training and a competency assessment prior to administering medicines • The ED provided services seven days a week. unsupervised. • The department had access to radiology support 24 • A housekeeper said they had undertaken induction and hours each day, with rapid access to computerised mandatory training, including safeguarding, manual tomography (CT) scanning, when indicated. ED handling and infection control. They said they had been consultants were contracted to provide cover 24 hours able to become involved in hand hygiene audits, per day, seven days per week, either directly within the infection control and environmental audits to facilitate department or on call. their development. Access to information

23 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

• The department had a computer system that provided up-to-date information about a patients’ condition and Are urgent and emergency services progress within the ED. However, patient information caring? about previous attendances was not available to the triage nurse as the nurse did not have access to the Good ––– computer system at the triage room. This meant that they did not always have sufficient information to The emergency department (ED) provided compassionate prioritise appropriately. care and ensured that patients were treated with dignity • Staff could access the trust intranet which allowed ready and respect. Patients spoke positively about the care and access to relevant clinical pathways, policies and treatment they had received and we observed many information. positive interactions. Staff provided patients and their • Patient investigation results were accessible families with emotional support and comforted patients electronically, including blood tests and imaging who were anxious and kept them informed about their reports. on-going plans and treatment. Consent, Mental Capacity Act and Deprivation of Feedback from patients, relatives and carers was generally Liberty Safeguards positive. All the patients and relatives we spoke with during our visits spoke highly of their care and the staff providing • We asked staff about the Mental Capacity Act 2005 and it. The response rate to the Friends and Family Test in the Deprivation of Liberty Safeguards. Staff knowledge was department was very encouraging, and the majority of variable and most of the nursing staff said the medical respondents provided positive feedback. There were staff were responsible for mental capacity assessments. positive comments from patients about the care received, • The staff we spoke with had knowledge about consent and the attitude of motivated and considerate staff. They and mental capacity. However, patients’ capacity and told us they were involved in the decision-making process any best interests’ decisions were not consistently and had been given clear information about treatment recorded in the patient records we reviewed during the options. inspection. • We observed positive interactions between staff, Compassionate care patients and their relatives when seeking verbal • The patients we spoke with reported that they received consent. The patients we spoke with confirmed their good quality care and support from staff. We observed consent had been sought prior to care and treatment patient-centred care and saw staff responding being delivered. respectfully to requests for support, even when they • The department’s mandatory training database showed were busy. We observed staff speaking kindly to patients staff had undergone safeguarding level two & three, but and talking with them in a friendly, dignified and none had undertaken mental capacity respectful way. training. Therefore the department could not be assured • We observed patient and staff interaction, during which that mental capacity was being staff demonstrated caring and compassionate attitudes adequately assessed. We observed nursing and medical towards patients. Patients told us their privacy, dignity staff seeking consent from patients before any care or was maintained at all times, and we observed staff procedure being carried out. pulling curtains around patient areas before completing care tasks. • Patients and relatives were confident about the care at the department, they told were caring and always did the best they can for them to make sure they were comfortable. • Staff we spoke with demonstrated an understanding of the need to recognise cultural, social, religious and

24 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

individual needs of patients. We noted that staff were • Nursing staff told us that counselling services were respectful and they maintained confidentiality around available to patients and their families and were always patients and relatives when communicating with people offered following the death of a patient. ensuring that patient’s information was protected. • We witnessed nursing staff providing patients and • The Matron told us, the ED participated in the NHS relatives with emotional support. For example, we saw a Friends and Family Test (FFT) and consistently scored an nurse took time to ensure that a patient who was being average of 65% response rate on a monthly basis, and admitted had the opportunity to inform their family 94% of the respondents recommended the department about their admission. to their friends and family. Nursing staff were given incentives on the number of FFT surveys their patients’ Are urgent and emergency services had completed, this initiative made the department’s responsive to people’s needs? response to the survey better than the national average of 57%. (for example, to feedback?)

Understanding and involvement of patients and those Requires improvement ––– close to them

• We observed staff involving patients and their families in Patients did not always receive timely care and treatment. their treatment and care. Staff involved patients and The emergency department was consistently failing to their relatives about discharge arrangements and asked meet the national standard that required 95% of patients them if they were happy with the plan put in place. to be discharged, admitted or transferred within four hours • Most of the patients we spoke with told us that they of arrival. were informed about their care at the department. They said staff dealt with their needs quickly and were polite The paediatric ED did not always meet the needs of when speaking to them. We observed staff explaining to children, due to staffing shortages of registered children patients if there was going to be a delay in seeing a nurses. doctor, the reason for the delay, and how long they Complaints were taken seriously. The team learned from would have to wait to be seen. Patients told us all the complaints received and reviewed ways to improve both staff explained the condition and progress in a way they their practice and patient experience within the understood, and all interventions were explained to department. them before it was conducted. • Parents accompanying their children in the Children's The department was able to demonstrate that despite the ED were positive about the treatment their child increasing demands and attendances, they coped with received. They said that the nurses and doctors were their routine workload. There was a slow response to assist supportive and understanding. a consultant undertaking initial assessments once the department became busy. Emotional support Service planning and delivery to meet the needs of • The hospital had a multi-faith centre, which patients or local people their families could use for prayers and emotional support. Members of staff from the chaplaincy services • The department had limited space that restricted visited patients and families on request. A patient told growth, and there was a growing population for the us they were offered a visit from the chaplain when services that were delivered by the department. required. • The adult’s ED had a ten bedded co-located CDU where • We observed staff giving emotional support to patients patients could be admitted for a short term stay to avoid and their families. They gave open and honest answers them been transferred to a ward. The unit was managed to questions and provided as much reassurance as and staffed by the ED team. possible. • The children’s ED had opened a two-bedded children’s day unit where children could be admitted under the care of the paediatric team during the day time. This

25 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

enabled continuity of care for patients requiring short • We saw patient information and advice leaflets however; term treatment and observation moving from the ED they were all in English and not in any other language or care to ward based care based in ED. It also avoided format. them being transferred to a ward, only then to be • The department had a room to accommodate a patient discharged after all the admission process had been presenting with mental ill health. initiated and completed. • Children’s needs were met by the provision of Access and flow age-appropriate toys and activities, a separate waiting • The hospital had an escalation policy that described the area and different pain-scoring tools. steps it would take when demand exceeded capacity. • The department had a notice board, which displayed Staff were familiar with this policy and were clear about information about uniform colours to enable patients to the importance of the hospital and the London understand the roles of staff according to the colour of Ambulance Service working together as a team to their uniform. address this issue. • The staff told us the department had an escalation plan • We spoke with the matron who was in charge of patient which described how it prepared in advance to deal flow at the department on the first day of our with a range of foreseen and unforeseen circumstances inspection. It was clear that the matron had a good where there was an unusually high demand for services. understanding of the process and the status of every However during our inspection we observed staff who patient. were undertaking initial assessment of patients coming under pressure due to a busy part of the day. It took • The percentage of patients seen within 4 hours was some time before extra staff were drafted in to help better than the England average before the merger and relieve that pressure. has since fallen to worse than the England 95% hospital standard target. It fell sharply in December 2014 to 81% • There was a waiting room for patients who brought and had since recovered to 90% or above from April themselves to the ED. The room was shared with the 2015 onwards. urgent care centre. It had sufficient numbers of seats, a • The percentage of patients waiting between four and 12 supply of drinks and snacks from a vending machine hours before being admitted was better than the and a television screen. England average before the merger in October 2014. • Patient pathways were put into action as soon the Since the merger, the trust was consistently worse than patient entered the departments. These meant patients the England average. Averages of 25% of patients were were seen and treated by appropriate staff, that waiting to be admitted in this timeframe between diagnostic tests were carried out, and results were January 2014 – July 2015. The England average in this reviewed promptly. timeframe was 10%. Meeting people’s individual needs • On the first day of our inspection, we found the • We saw that the department had champions who led on department was not busy with just about six patients in specific areas to facilitate individual needs, such as the department. Although most of the patients had learning disabilities and dementia care. Staff we spoke been in the department for less than four hours, one with were aware of the needs of patients with learning patient had been in the department for over 12 hours. difficulties and had a good knowledge about how to There were a number of reasons that led to the patient support people living with dementia. Patients with breaching the four hour target including waiting for the complex needs were flagged up and assessed as Psychiatric Liaison team, and the matron was aware and appropriate. Chaperones were available if required. gave us an assurance about the breach. • Staff had access to translation services by way of a • We went again when the department became busier. telephone interpreter system. They told us that the There was one consultant with an inexperienced nurse system worked well whenever they were required to use carrying out initial assessments rapidly becoming it. overwhelmed by the number of patients coming in on

26 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

ambulance trolleys. It took some time before additional informed of the progress through meetings and letters assistance from within ED was given. We were not to the complainants. Learning from complaints was assured that this situation would not happen again disseminated to the whole team in order to improve once we stopped observing. patient experience within the department. • We observed London Ambulance staff waiting with their patients until the ED staff were able to book them in. At Are urgent and emergency services one point there were up to four patients on trolleys waiting. Discussions with staff indicated that in busy well-led? periods patients and ambulance crew waited in the corridor leading to the ED. We received only trust wide Requires improvement ––– information on black breaches ( where handovers from ambulance arrival and the patient being transferred to The ED had governance arrangements that included ED took longer than 60 minutes). These were reported monitoring risks and quality of service provision. There was as varying from a high of 242 in December 2014 to a low an appropriate escalation process for risk, however local in June 2015 and starting to rise again as the year leadership (medical and nursing leadership) had expressed progressed to 91 in August 2015. a sense of isolation from the rest of the trust. • The national average for percentage of patients who The vision and strategy of the department was not made had left ED before being seen was 2% - 3%. The average clear to the local leadership by the corporate management for the Ealing ED department between from January of the trust. Most of the staff said clinical leadership was 2013 – March 2015 ranged between 2% - 3.5%. This is good. However we found that action plans were not the Department of Health (DoH) indicator, which developed or implemented in response to any potentially showed patients were dissatisfied with the deteriorating performance and CEM audits in the length of time they waited to be seen at the department. department. Learning from complaints and concerns Staff told us that the ED had an open and honest culture • The Patient Advice and Liaison Service (PALS) was and excellent teamwork. Medical and nursing leadership available throughout the hospital. Information was were constantly visible in the clinical environment. The available for patients on how to make complaint and leadership team demonstrated the skills, knowledge and how to access the Patient Advice and Liaison Service. experience needed for their roles. Information about PALS was displayed in the department for patients and their representatives. Vision and strategy for this service • Staff understood the process for receiving and handling • The future vision of the trust was not embedded within complaints and told us information about complaints the department or the team and most of the staff we was discussed during routine team meetings to raise spoke with were not able to articulate the vision and staff awareness and aid future learning. We were told strategy of the trust. Senior staff said there was little that the overall complaint response rate at the hospital strategic and leadership direction from the corporate was 85%, most of the complaints regarding ED was team, even though they had their own ideas on the about waiting times, communication, and discharge vision of the ED. process. We were provided with documents detailing • Staff in the department, were unclear about the future the actions taken to address complaints and concerns, of ED services at the hospital. They were told that the this including meeting the complainant, talking to staff trust intended to close the department in the future. and discussing complaints at team meetings. Most of the staff we spoke with were concerned about • The Matron was able to describe the complaints they what the future of ED and the hospital at large, and they had received in the last year and gave details of the were not aware of what the future plans were for the complaints investigated and how the patients were kept department and the hospital.

27 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

• The senior management team were interviewed • Feedback from junior doctors and junior staff nurses separately and we noted that their vision was not working in the department was very positive. They aligned with one another for the department. Both local commented that they had been made to feel part of the and corporate leadership spoke about different team and senior staff ensured they were able to be priorities and issues concerning the department. involved in all aspects of patient care and treatment. • Nursing staff told us the new senior management team • All the staff that we spoke with said that they enjoyed were not visible. Most of the staff we spoke with had not working in the department and reported being well seen any of the new trust leadership in the department, supported. They were clear about what the department and they did not know them. However, most of the staff did well and where it could improve. spoke very positively about the matron, her senior • The trust had very recently merged with another trust nurses and how supportive they were, and said they and appointed a new chief executive about 6 months could go to them with issues. ago. The chief nurse had been in post for a few weeks • At the time of the inspection, there was a lack of joint prior to the inspection. ownership of the issues faced by the department across the trust, because the local leadership and the overall Governance, risk management and quality trust leadership vision of the department were not measurement aligned with each other. • There were no risk assessments associated with the • Staff were encouraged and supported to report any availability of only one monitored bed and the lack of issues in relation to patient care or any adverse kitchen to provide patients with hot meals at the incidents that occurred. We observed staff from all department. specialities worked well together and had mutual • Governance meetings were held within the department respect for each other’s contribution to the holistic care and all staff were encouraged to attend, including junior of their patients. members of staff, lead nurse and governance committee Staff and public engagement members. Complaints, incidents, and quality improvement projects were discussed. We reviewed • The matron informed us that staff were told to actively minutes from the meeting on 13 July 2015, which engage with patients and encourage them to complete showed a comprehensive review of new incidents, the the Friends and Family test. This resulted in a mixed risk register, audits, monthly mortality report, response rate for the department. For example in August safeguarding, complaints, training and on-going issues. 2015, the department response rate was only 18% The clinical governance committee reported to the trust against the trust response target of 40%. quality committee. • Most of the clinical and non-clinical staff we spoke with were not aware of any public engagement initiatives by • The department maintained a system of quality the department whereby input from patients was indicators for monitoring targets; for example, national sought to help improve the overall ED experience. performance targets, patient safety and quality, NHS Safety Thermometer, patient experience and workforce • There was no evidence displayed in the department of and safer staffing. These were accessible by all staff for changes made as a result of patient feedback such as reference. waiting times, Friends and Family tests or patient-led • Regular liaison between the two ED’s (Northwick Park assessments of the care environment (PLACE). and Ealing) was not evident. At the time of our Innovation, improvement and sustainability inspection, it was ad-hoc and informal. We were informed that such liaison would be useful in imparting • There was evidence of innovation in relation to learning lessons learned from incidents and communicating and development. For example the department had good practice across the two departments. introduced a Schwartz Round Centre on a monthly basis. A Schwartz Round is a multidisciplinary forum Leadership and culture within the service where clinical and non-clinical staff meet to discuss

28 Ealing Hospital Quality Report 21/06/2016 Ur g ent and emer enc y ser vic es

Urgent and emergency services

emotional and social dilemmas that arise in caring for patients. The purpose of the round is not to solve problems, but to explore the human aspects of delivering care that staff face from day to day.

29 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

Safe Requires improvement –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

Information about the service Summary of findings Inpatient medical services at Ealing Hospital (EH) Medical services required improvement at EH in safety, compromised of wards 4 South (Cardiology), 5 North and effectiveness, responsiveness and leadership. We were South (Care of the Elderly), 6 North (Gastroenterology and particularly concerned about the sustainability of endocrinology), 6 South (Respiratory), 8 South (Infectious already stretched staffing levels when a new ward will Diseases), and the Acute Medical Unit (AMU). be opened at Northwick Park which some recently There were 10,400 medical admissions at Ealing hospital appointed staff will be allocated to. in 2014/2015, including 53% emergency, 2% elective, 45% Patient records were not complete or patient focused in day case. Of these 66% were general medicine, 13% a number of instances. clinical haematology, 9% cardiology, and 12% in other specialities. There was some over reliance on junior staff and there was a lack of cross site governance and working. We visited all the wards that were open over the course of a one day announced visit and another evening which Discharges were constantly delayed and patients were was unannounced. We spoke with 34 members of staff not always cared for on the correct ward. There was a including nurses, doctors, allied health professionals lack of support and communication from divisional such as pharmacists, ancillary and administrative staff. level. This included department and divisional management. However we found caring was good overall with positive We spoke with five patients, checked 14 pieces of patient feedback and improving friends and family test equipment and 31 patient records. We also observed care scores. and reviewed other hospital records including policies, procedures, meeting minutes and audits. Incidents were mostly learnt from although only if they occurred locally. There was awareness of the Mental Capacity Act and pain relief was well managed. There was good patient flow through the AMU and complaints were learnt from. There was support from local leadership and some performance oversight.

30 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• However, we did find a few members of staff were Are medical care services safe? unclear what constituted a serious incident. One example was not declaring a grade three pressure ulcer Requires improvement ––– as a serious incident, which is contrary risk rating criteria. Staff also reported not getting learning from Safety on medical wards at EH required improvement. incidents from across the other trust locations. There was a lack of both permanent medical and nursing • We reviewed five root cause analyses of serious staff and although this was improving, we were incidents, which included one, we could identify as concerned a high number of recently recruited staff occurring at EH. The investigation did not follow a would soon move to the new AMU at Northwick Park proper root cause analysis process with only an incident which would then increase the vacancy rate again. Most background, medical history of the patient and patient records we reviewed were either incomplete or chronology. There were no contributory factors, root not fit to meet the patient’s needs. Investigations into cause or recommendations stated. serious incidents did not follow best practice. There were • Staff were aware of their responsibilities under Duty of some concerns with cleanliness and the state of repair or Candour including the need to apologise after an servicing of equipment and fixtures. incident and the need to share the investigation with the person affected. There was a trigger on Datix for However mandatory training rates were improving. duty of candour when an incident was moderate or Deteriorating patients were identified and escalated as above. Training for duty of candour was part of risk needed. Incidents were reported and learnt from at a management training. Duty of Candour is a regulation local level. Patient harms were around the national under the Health and Social Care Act which aims to average other than a high rate of falls in some areas. ensure that providers are open and transparent with Medicines were mostly well managed and stored people who use services and their carers. It sets out securely. some specific requirements that providers must follow Incidents when things go wrong with care and treatment including informing people about the incident, • There were 17 serious incidents declared by medical providing reasonable support, providing truthful services at EH but none in recent months. Three were information and an apology when things go wrong. grade four pressure ulcers (PUs), three were grade • We requested mortality and morbidity meeting (M&M) threes PUs, two were falls, and there was one each of minutes but the latest we received were for April 2015 various others including ambulance delays, medicine and only focused on infectious diseases although errors, and safeguarding incidents. previous minutes had other specialities. None of the • There were a total of 9402 incidents reported in the trust staff we spoke with told us M&M meetings took place. wide medical services in last 12 months. These were Clinical governance meetings acknowledged that M&Ms mostly PUs, admission delays, falls, and administration only occurred ad-hoc across the division. of medicines incidents. • Staff were aware of how to report an incident and Safety thermometer received individual feedback. Although agency staff • Safety thermometer results were displayed in all the could not report incidents themselves as they did not ward areas we visited, including staffing levels, pressure have access to the system, they knew who to report ulcers, urinary tract infections, and falls. Across the trust, them to. Staff were able to give examples of incidents pressure ulcers, UTIs, and falls were around the national that had occurred and were able to describe actions average. Audits for care bundles relating to patient that were taken to stop further incidents in the future harms were mostly 100% or just below 100% and we such as checklists for allergies. A lesson of the week found very few of these care bundles were not meeting was undertaken every Friday in the AMU where completed. staff could present an item of learning from an incident • Falls were a particular concern on the care of the elderly they had been involved in. wards, particularly 5 North ward where there had been over 30 in 2015/16 compared to nearly 20 on 5 South

31 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

ward. Although no patients had suffered a fracture, we guidance. Audits showed hand hygiene was a concern asked why there had been a high level of falls on 5 North with some wards either not submitting audits or scoring ward. Senior staff were not able to tell us although they less than 90%. However, we found staff mostly observed acknowledged there were less health care assistants on appropriate infection prevention and control guidelines this ward compared to 5 South despite being staffed to such as wearing personal protective equipment and patient acuity and dependency. washing hands between patient interactions. • In more recent months, 6 North ward had a higher • Staff observed bare below the elbow practice in all amount of falls than the care of the elderly wards. Senior clinical areas that we inspected. nursing staff acknowledged this but they said this was Environment and equipment due to the patient group as many had alcohol related impairments although we observed patients were well • Most of the equipment we checked was clean. Those supervised. A falls committee did take place but was that were had stickers to show they had been cleaned in always based at another trust site. the last 24 hours. In addition, servicing of equipment was up to date. Cleanliness, infection control and hygiene • We found a sink that was in a state of disrepair, toilet • There had been some acquired Clostridium Difficile but seats that were cracked or unclean and shower curtains they were in different wards and there was no that were in poor condition. However, when we pointed identifiable trend. However although Methilicin resistant out the areas that required cleaning, staff attended to staphylocous aureus audits showed mostly 100% or them immediately. near compliance, we found most patient notes showed • Resuscitation trolley checks were not always up to date swabs had been taken but no result had been recorded. and some were only conducted weekly. • We observed all the medical wards to be clean and tidy • Temperatures in the bathrooms were significantly including sluice areas. It was particularly impressive on 6 colder than the rest of the ward. North ward where sluices and commodes were cleaned • Some staff told us equipment that required repair or at least three times a day. This was recorded on the replacement could take some time unless it was urgent. equipment. Patients we spoke with also said the Staff told us some items that had required maintenance hospital was mostly clean. for months and had only been repaired in recent weeks. • The utility room for the AMU was not separated between Medicines "clean" and "dirty" areas due to its size and we found a dirty shower seat in the AMU. This was cleaned once we • Patients that needed oxygen had oxygen prescribed brought it to the staff’s attention. We requested appropriately although there were a few errors and cleanliness audits but did not receive any for EH other sometimes where limited oxygen was prescribed than the AMU. This scored 90% but had issues with unlimited oxygen was given (for example as the driving walls, TV, floor, high surfaces, alcohol dispensers and gas for a nebuliser). curtains and some areas were not scored. • The fridge in one of the wards did not show a stable • There were no sinks in the rooms on the infectious temperature with different recordings between the diseases ward; staff had to wash their hands outside in thermometer on the inside and the displayed the main ward corridor before entering. In addition, temperature on the outside with one of these over the none of the rooms had negative or positive pressure to required temperature to keep medicines cold. There control the airflow going into or out of the rooms were also no recorded actions to show what was to be despite requiring at least two. This arrangement was not done and staff were also not clear on what action was appropriate particularly for an infectious diseases ward. required. However, later in our inspection, the trust • Although there were appropriate bins in all areas, their installed a new fridge. use was not always appropriate with medicine bins • Intravenous fluids were appropriately stored and used for sharps. locked. Patients own medicines were locked away • Senior staff told us the infection control team needed to appropriately and not used during their admission but train and support the ward staff more in areas such as given back on discharge. However, staff we spoke with confidence in challenging doctors who do not adhere to were unaware if there was a self-administering policy.

32 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• Staff told us to take away medicines (TTAs) were kept in recorded but not on the weight chart. Fluid balances cupboards locally on the ward. However, we did not find charts were not totalled, MRSA swab results not this was the case when we checked the cupboards recorded, and dementia questions not answered. ourselves. Another had no score for the waterlow skin assessment, • The use of summary care records (SCR) had been no record of the fluid output, and no result on the MRSA implemented at Ealing hospital to assist with the swab. Some of the nursing assessments were not dated. completion of medicines reconciliation, which both We found two sets of notes where a night entry had pharmacists and pharmacy technicians were trained to been completed for a patient regarding their sleep at carry out. The medicines management technicians were the start of the night shift and multiple others where also trained in medicines reconciliation and they were times of review had not been recorded. When we spoke accredited via London Pharmacy Education and with staff about the quality of patient records, they Training. agreed there was a lack of personalisation and were • There was evidence of good antibiotics stewardship. incomplete in places. The antibiotics section of the Ealing hospital drug chart • An electronic record system (EPIC) was in place on the had been designed in such a way that it ensured that a AMU and care of the elderly wards, which was user doctor reviewed the need for the antibiotic after three friendly. It showed when patients were within 48 hours days, and again after seven days. The indication for the of expected discharge, if they were medically fit; if there antibiotic was required on the drug chart, as well as the were any conditions or support arrangements that staff name of the staff member from the microbiology team needed to be aware of such as allergies or learning that was involved in the decision to prescribe the disabilities as well as if a patient was due for a doctor antibiotic. Gentamicin and vancomycin both had their review due to a high national early warning system own drug charts, which prompted the clinicians to take score. the relevant drug monitoring levels before the medicine Safeguarding was continued. Point prevalence studies (an assessment of the use of antibiotics and level of compliance with the • Staff were aware of their responsibilities to safeguard antibiotics guidelines) were conducted every six vulnerable adults and knew whom to report any months, and the outcome data was then fed back to the concerns to. antibiotics stewardship group and the Drugs and • We saw examples of safeguarding referrals which were Therapeutics Committee. mostly when a pressure ulcer had either deteriorated or been acquired. However not all acquired pressure ulcers Records had been referred for safeguarding. • Most patient notes we checked had illegible signatures • We received the mandatory training results for and medical staff did not always use stamps or print safeguarding both adults and children at level one to their names to show who had reviewed the patient. The three for July 2015 and these were split by both medicines safety team had undertaken a recent audit speciality and staff group. They showed variability in on this and results were due shortly. However a records completion with a number of areas at 100% in all their audit in 2015 reviewing 50 notes across seven safeguarding training but others at around 50% or lower specialities stated most notes were fully complete with including cardiology (administrative, health scientists dates and signatures with all at least 75% fully correct, and medical staff), gastroenterology (medical), general which was much better than our findings. medicine (medical and nurses), acute medicine • Care plans were not personalised to individual patients. (medical), care of the elderly (medical and additional Falls, diabetes and hygiene plans to mitigate risks were clinical staff). all pre-populated and therefore were at risk of not Mandatory training meeting patients’ individual needs. They did not always describe why there was a risk or the actions did not • Staff told us they were up to date with their mandatory correlate to all the risks described. training and figures showed training rates had been • Some aspects of patient records were incomplete. For improving to around or over 80% overall after some example one set of records had a patient’s weight wards were below 70%.

33 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• Staff said their line managers prompted them when a cared for patients with tracheostomies and non-invasive course was due for renewal. However, staff still were ventilation and staffing was not always increased to concerned that they had to complete training in small meet the numbers of these patients. This meant the modules on the new ‘ELMS’ system rather than all in one establishment did not comply with the or two days as they used to. They said this had a recommendations of the British Thoracic Society/Royal negative impact both on the training rates and the College of Physicians of London and Intensive Care ability for staff to take time out to train. Some staff told Society for nurse patient ratios for those receiving NIV or us they had completed training outside of work time to having tracheostomies. Eight nurses covered six get up to date. patients each though non-invasive ventilation (NIV) patients were supposed to have one nurse per two/ Assessing and responding to patient risk three patients. We were told if there were over five NIV • All the national early warning scores (NEWS) were patients admitted, some would go to the cardiac ward checked. They recorded that patients were observed as there were NIV trained nurses there. The coronary and escalated appropriately if they deteriorated. care unit (CCU) had three nurses covering up to four Interventions by medical staff or the critical care patients each whereas the cardiac ward had three outreach service (CCOT) were timely when a patient was nurses and two HCAs covering up to 24 patients which escalated to them. Audits showed NEWS were being dropped by one HCA at night. The care of the elderly recorded and patients escalated appropriately. wards were not meeting the skill mix required for the patients they cared for due to the lack of nursing Nursing staffing retention with nurses moving to other departments in • The trust stated they set staffing levels to a minimum the hospital. This meant there was a lack of band 6 nurse to patient ratio of 1:8. Although there were still nurses and over reliance on overseas nurses, although high vacancy rates on medical wards (around 20% from they were on conversion courses. 40% a few months before), we found staffing levels were • Some HCAs told us they were overstretched. On one either at or better than the acuity and dependency of ward, two HCAs covered 12 patients each. There were the patients on most wards and these were maintained. also concerns that there was a higher use of agency at One ward had deliberately increased its establishment night. of health care assistants. This was to ensure it did not • Agency staff used were mostly regular to the hospital. have to constantly request additional ones for patients Staff confirmed there had been high amounts of agency that required one to one care as they were required so staff but this had recently decreased which had often. This meant five registered nurses and six health improved the quality of care. However concerns were care assistants covered 30 patients. Other than the raised by staff regarding the process to approve agency nurse/patient ratio referred to above we did not see and additional staff. Approvals were required by the evidence of a recognised acuity tool being used to divisional team rather than by the department or determine specific nurse staffing levels. matrons. This meant the process could be lengthy and • We were concerned vacancy rates would go back up as at risk of not being approved in time. The process had some of the staff were due to move to the new AMU at been changed in recent months by the executive team Northwick Park once it opened. to reduce the amount of staff spending at the trust. This • Staffing at night was more stretched. There were a was particularly difficult for Ealing as they had less bank higher amount of agency staff at night and although staff to use. they had an induction checklist, we were concerned this • Ward managers were supernumerary and rarely had diluted the skill mix as agency nurses were not always clinical duties. However, although there were clinical trained in the ward speciality such as non-invasive educators in the hospital, there were no practice ventilation (NIV), heart failure or diabetes. On AMU, 60% development nurses (PDNs) dedicated to the wards of the staff at night were agency. Otherwise agency use which is contrary to Sir Robert Francis’ we observed and recorded was around 30%. recommendations although they were trying to recruit. • The staff ratio for the acuity and dependency on the The last PDN had recently left. respiratory ward was not always appropriate as they

34 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• Handovers were not always appropriate as sometimes • There was a lack of permanent consultants with two agency staff were handing over to each other with no locums and one permanent consultant covering the permanent staff involvement. In addition, handovers we care of the elderly wards and two out of three of the observed had no staff huddle, only a nurse to nurse respiratory consultants were also locums. It is not clear bedside handover which meant staff were not aware of whether this was on the Trusts risk register but as a any patients in another bay. Also the bedside handover result of this and other factors, trainee respiratory/ focused on the nursing side of care such as assessments general medical registrars had been removed from and not treatment plans or social history. However, Ealing Hospital further compounding the problem. This there was a handover checklist that was completed and had an effect on care of the elderly wards as they said both staff had to sign to ensure handover had occurred they did not have enough time to participate in national although completion of the forms varied from ticking audits so they were unable to tell us about patient the relevant assessments to dating when they had been outcome performance. Recruitment for a geriatric completed. consultant had been ongoing but unsuccessful. Senior • Senior staff acknowledged there was difficulty in staff acknowledged recruitment and retention was recruiting staff due to the perception of services closing difficult due to the perception of services closing at at Ealing, particularly for the respiratory ward. However Ealing so they were looking at recruiting consultants to recruitment drives were ongoing including weekend work cross site. However some staff were worried that recruitment days and right registered nurses had been this was unlikely to succeed. recently appointed from overseas. • At night, first year junior doctors (FY1s) covered medical • To increase retention, overseas nurses were buddied up wards unsupervised. There was a medical registrar on together and had a competency programme such as site and consultants were on-call but juniors told us the supernumerary working, and social events with a senior doctors were often in A&E clerking patients. non-overseas nurse overseeing them. Encouragement They perceived a lack of support from some of the was also given to student nurses to take up their on-site team as a result. qualified posts at the hospital. Rotation was also being • There were no plans to recruit physician associates or looked at. acute care practitioners although senior staff • Some staff were permanently rostered to conduct night acknowledged it may be an area to look at in the future. shifts and/or weekends and this had led to concerns • Ward rounds across the services were daily led by the about their training and development. consultant on shift that day with a grand round once a • We saw no evidence of comprehensive recruitment and week for clinical teaching. retention plans beyond the use of bank and agency staff • Patients who were outliers were cared for in different and ad hoc measures described above to fill vacancies. ways. On some wards, the host speciality would take on We did not see displays on the wards of planned versus their care after an initial review by the speciality actual staffing. We did not see a red flag system when pertinent to the patient’s condition. For other patients, staffing levels fell below a certain level. there was dual care, with reviews by both the pertinent and host specialities, mostly when a patient had Medical staffing multiple co-morbidities in different specialities. • We were satisfied with the amount of junior medical • There was one registrar on-call for the gastrointestinal staff on shift. Care of the elderly wards had a registrar, bleed rota each day with a second on-call on the wards senior house officer (CT1) and three house officers (FY1 at weekends with each registrar conducting around one and 2s) which staff said was sufficient. The haematology shift a week and one in six weekends. However we ward had two junior doctors (an SHO and a registrar) on found patients were being transferred to Northwick Park shift each day. The diabetes and gastroenterology ward for endoscopy. had three consultants, two registrars (one was locum), Major incident awareness and training two clinical fellows, two CT1s and three FY1s. Consultants on this ward were on shift for two weeks • There was some awareness of major incident plans. before a rotation. Staff were aware of what a major incident was and knew they had to respond but were sometimes unclear on

35 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

what the procedure would be. For instance, there was • An audit was conducted on use of reusable tourniquets limited awareness on the criteria for discharging for venepunctures (taking blood samples) by junior patients in the event of a local major trauma incident doctors as use of these is contrary to infection control such as a motorway pile up or airline crash. guidance. This found a high proportion of junior doctors both when audited initially and re-audited, were using Are medical care services effective? either reusable tourniquets or gloves rather than disposable tourniquets. Requires improvement ––– • We received a number of other NICE audits that had been conducted but they were in 2013 or 2014 despite our request that they be within the last 12 months. We The effectiveness of medical services required were therefore unable to review the most recent improvement. There was a lack of nutritional and fluid performance. monitoring. There was local auditing which was showing improvements in a number of areas but a number of Pain relief audits had not been completed for over two years. There • Patients told us their pain was controlled and records was a lack of multi-disciplinary working cross site. showed pain scoring was undertaken and appropriate However national guidance was mostly followed, pain pain relief given when appropriate. relief was well managed, appraisal rates were improving • Staff were complimentary about the pain team although and there was an understanding of the Mental Capacity most of their interventions were for surgical patients. Act and Deprivation of Liberty Safeguards Nutrition and hydration Evidence-based care and treatment • We had concerns about the management of patient • We found evidence to show that the wards were nutrition and hydration: complying with national guidance such as National • We observed and patients also told us that they always Institute for Health and Care Excellence (NICE) including had something to drink that was within their reach. local policies and procedures and updates in • Most patients were happy with the choice of food department meetings. Some staff were using including roast dinners on a Sunday. applications on their mobile phones to look up national • However, Malnutrition universal scoring tool (MUST) guidance. assessments were either not completed or not • Early warning score audits were in line with national completed appropriately in many instances. In addition, guidance. fluid balance charts were also either not completed or • Daily checklists were supposed to be completed by the not completed appropriately. For example, some nurse in charge regarding displays on performance, patients had high body mass indexes but these were not signage, equipment, call bells and cleanliness. However flagged as a risk despite scoring on the MUST. Fluid the checklists we reviewed had multiple days where no balances were not totalled. Audits for nutrition were checks had been conducted. variable with most wards scoring over 90% but 6 South • An alcohol withdrawal audit was undertaken in 2015 ward scored 73% compliance. reviewing the clinical institute withdrawal assessment • Staff were complimentary about dieticians but they (CIWA). This showed a big improvement on use of the were only available on a referral basis. CIWA since 2013 from 8% use of the tool to 73%. • Food standards were mostly RAG rated by the • An audit on the use of high dose statins after an acute hospital as amber other than menu planning, and MUST myocardial infarction (heart attack) took place in 2015. It which were rated by the hospital as Green.This did not found only 64% of patients were given the correct dose correspond with our observations. of statins on discharge out of 25 patients and no reason • We did not observe nursing staff actively assessing or for the incorrect dose was given. Recommendations promoting oral hygiene and mouth health in their were made including checklists at discharge. patients. We did not see any trust guidelines or policies on patients' oral hygiene.

36 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

Patient outcomes the ward took on the less acute patients such as no NIV. However the trust induction for new permanent staff • There was a lack of national auditing on patient was not always appropriate with a lack of a outcomes in some areas. The care of the elderly wards comprehensive corporate and local induction which did not participate in fragility audits and claimed that a sometimes comprised of very few days before starting lack of permanent consultants prevented them from shifts and being counted in the shift numbers. doing so. Staff were unaware of any national or local audits specific to infectious diseases or haematology. • Appraisal rates as of July 2015 in medicine varied from • EH had a better than average performance in the above 80% to below 50% in some wards with a trust Myocardial Ischaemia National Audit Project (MINAP), target of 95%. We received varied feedback regarding particularly for admission to the cardiac unit. appraisals with some staff happy with their appraisal • EH had a worse than average performance in the which they received regularly whereas others said they national diabetes audit (NADIA) in 14 of 21 indicators either rarely had them or not at all. Appraisal rates including medicine errors, prescription errors, reviewed showed some wards had completed their management errors, insulin errors, foot risk assessment appraisals in summer 2014 which meant their overall in 24hrs, foot risk assessment during stay, meals, self rate was low as they were trying to catch up, whereas management of diabetes care, staff awareness of others had better maintained their appraisal rates as diabetes care, and staff knowledge on diabetes. Staff they had been staggered throughout the year. Specialist told us there had been specific teaching in relation to medicine staff told us their appraisal rate across the this audit such as safe prescribing of insulin. A new trust was 71% but could not give us information site NADIA audit had recently been completed and staff specific. believed they had improved their outcomes this year • There were no practice development nurses but there although the report had not yet been published. Other were clinical educators although they were not diabetes related audits that had been undertaken dedicated to individual wards or areas. including acute kidney injury and foot examination • Nurses were able to undertake mentorship courses but although staff were not aware of the results of these there was variable feedback from nurses on whether either. they received patient specific training such as dementia • Average length of stay (ALOS) was lower than the or diabetes. On the respiratory ward, all but two national average for elective patients but higher for permanent nurses were NIV trained and band six nurses non-elective, particularly in care of the elderly wards. We were critical care trained with plans for band five nurses found discharges were often delayed which was to be trained as well. There were tuberculosis (TB) contributing to this. specific nurses on the infectious diseases ward who • Patient satisfaction data was collected using a tablet at undertook HIV and TB courses. Clinical nurse specialists Ealing hospital pharmacy outpatients and this data were available for patients with diabetes. Shift and helped to inform interventions to improve the patient patient allocations were made depending on the experience. For example, patients expressed that they training staff received. wanted more confidentiality when speaking to staff at • Junior doctors gave mostly positive feedback about the pharmacy hatch. As a result, two glass panels were their support including regular training, appraisals and installed either side of the pharmacy hatch to increase variation of work. They told us there was an opportunity patient confidentiality. to shadow before being on shift and they received good • The hospital was not an outlier for mortality on data documentary advice and support. However we were which CQC held, but the division had no mortality concerned about the responsibilities they were being statistics on its monthly performance dashboard. asked to undertake when there was either a lack of on-site supervision or the frequency of their rotas. Competent staff Junior doctors said on-call was onerous. They said that • Agency staff were appropriately inducted with checklists site team support was variable and that there appeared and orientations completed before they started a shift. Those that did not have the particular competencies for

37 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

to be a lack of transparency as to the amount of nights • Pharmacy was open Monday to Friday, 9am to 6pm. juniors undertook. Some of the patients we spoke with Pharmacists undertook bespoke ward rounds. On AMU at our listening event said that trainee doctors were not there was a band seven pharmacist with a pharmacy always carrying out procedures correctly. technician or part time pharmacist on week days plus a supernumerary pre-registration pharmacist. Multidisciplinary working • There was seven day working for all types of therapists • There was a lack of multi-disciplinary (MDT) working and pharmacists including on the wards with a cross site. Tissue viability services worked cross site and pharmacist between 9am and 1pm at the weekend. some of cardiology and respiratory services. There was • There was an on-call pharmacist available on all sites also some systems working multisite such as the picture who could be contacted out of hours for assistance with archiving and communication system (PACS). However, medicines supply issues. However they were not staff we spoke with in the pharmacy departments had commissioned to dispense discharge medicines out of not met and did not know their counterparts at the hours for patients wanting to go home. There was also a other sites. This was contrary to information we received medicines helpline available for patients discharged at a focus group. Other staff said and meeting minutes from the trust. showed there was very little cross site working in the • The respiratory ward had a dedicated physiotherapist different specialities. who also was responsible for the ITU and they were • Although there were meetings with community services, on-call at weekends. Care of the elderly wards had senior staff said the services were not joined up. There dedicated physiotherapists and occupational therapists were plans to rotate staff between community and who were available on-call at the weekend. Imaging was acute for heart failure and diabetes as well as available seven days a week although only urgent scans integrating pathways. could be done at weekends and there was no bone • All patients on AMU were discussed across all density scanning at the hospital. specialities every morning regarding their last 24 hours • Consultants were available on-call out of hours with a and reviewed on a ward round and bed meeting in the medical registrar the most senior clinician on site. afternoon. Nursing staff described a good relationship However there was seven day working during the day with doctors and therapists including at night. with consultant presence. • MDT meetings occurred on the care of the elderly wards Access to information daily and for tuberculosis patients once a month which included case reviews but also other areas such as drug • The IT system sent an email to the patient’s GP when a errors and new NICE guidance. consultant treated them, with electronic discharge • All types of therapy visits were unscheduled so we were summaries and clinic letters sent. concerned patients could miss their therapy if they were Consent, Mental Capacity Act and Deprivation of away from their bed or in pain. Liberty Safeguards • There were links with Harefield Hospital for long term NIV patients. • Staff were aware of their responsibilities to undertake • An MDT records book was kept on wards but this only Deprivation of Liberty Safeguards applications when documented a brief summary of an intervention for a patients were restrained from leaving the premises patient such as ‘wean from 02’ and ‘community rehab against their will and we saw examples where this was referral’. It was not clear how useful this would be as a in place. communication form between different staff groups • Staff knew their responsibilities under the Mental other than as an aid memoir for them to look in the Capacity Act including the process for a doctor review of patient notes. their capacity and best interest assessment if needed. We saw examples of best interest assessments Seven-day services completed and these were appropriate such as use of mittens when patients were pulling out their intravenous lines.

38 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• We saw examples of staff using appropriate • We observed a few occasions where staff were talking to de-escalation techniques to calm down agitated each other in another non-English language within patients without having to use restraint. hearing distance of patients where it was not the patients’ own language. Are medical care services caring? • Medicine rounds took place at 6am. This meant some patients had to be woken to ensure medicines were Good ––– taken. • Handovers we observed did not involve the patient. Staff talked between each other at the patient’s bedside Inpatient medical services were caring. Patient feedback and only friends and family got involved when staff was that they were cared for with privacy and dignity. wanted clarification. There was no explanation to the Patients, family and friends said they were involved in patient or family about what the handover was or what their care and emotional support was available. they were discussing despite the patient’s being However, we observed some instances where patients conscious. were not involved in their care because staff talked over Emotional support them. • Psychiatric support was available for patients and their Compassionate care family if they wanted it. Nurses told us psychiatric • All the patients we spoke with were happy with their support was available on referral and they were care from all staff groups. They told us their privacy and responsive including at weekends. This included MDT dignity was maintained during personal care and that meetings with those involved in the patient’s care. staff were kind and caring. Nurses answered call bells quickly. Patients were not woken for washes at night Are medical care services responsive? unless they were required. However, a few patients told us they had not seen a doctor every day. Requires improvement ––– • Friends and Family Test (FFT) response rates were above average at 41.8% with some wards getting a 60 to 80% The responsiveness of inpatient medical services response rate. Eight wards scored between 46 and 100 required improvement. There were constantly delayed with most at or above 93% recommending or highly discharges which was leading to patients acquiring other recommending the trust. However the AMU response conditions and arrangements to support discharge were rate was low at 8% and some ward were not reporting not adequate. There was a lack of accommodation scores in some months. arrangements for families to stay overnight. The hospital Understanding and involvement of patients and did not meet the environmental requirements for those those close to them that were immunosuppressed or infectious. Medical patients were often cared for on the incorrect speciality • All the patients, family and friends we spoke with told us ward. There was a lack of support for patients living with they were involved in their care with treatment and dementia. options explained to them in ways they could understand or repeated in a different way. However flow on admission was well managed from the • Some nurses we observed did not have name badges AMU to the speciality ward. Referral to treatment targets which meant patients may not have been able to were mostly met. Complaints were learnt from although identify them. This was confirmed by some patients we there was a lack of physical evidence this was the case. spoke with at our listening event. However, patients told Service planning and delivery to meet the needs of us there was some continuity of care of those nurses local people looking after them each day.

39 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• Visitor hours were normally restricted but we saw discharged if they only required a follow up examples of where this was relaxed depending on the appointment with an acute physician. Delays often circumstances. occurred when discharging from a specialist ward, • There was no accommodation on site for visitors or any particularly on the care of the elderly wards. local arrangements with hotels or other • There were no ward based discharge coordinators so accommodation providers. Those that required to stay continuing care assessments and other social services over were made as comfortable as possible on chairs in paperwork either had to be completed by the nurses on the patient’s room but the chairs were not designed to the ward or the hospital wide discharge sleep in. coordinators. On one ward we found eight patients that • Due to the lack of side rooms at the hospital, there was were medically fit and waiting for discharge. Although pressure on the infectious diseases ward to take discharges did occur at the weekend, these were patients who required a side room such as those at the discharges that did not require social services end of their life or those who were infectious. However involvement. this sometimes meant patients that should be admitted • Senior staff acknowledged there was a discharge issue for that ward sometimes had to be admitted elsewhere but their opinion was that the issue was mostly a lack of and moved later on. nursing home placements in the community. Plans were • There was a lack of entertainment facilities such as in place to train nursing staff on home care assessments televisions on the wards. so they did not have to rely on the discharge • The latest Patient Led Assessments of the Care coordinators. Environment found Ealing Hospital was below the • A discharge lounge was available for patients waiting for national average for every indicator and particularly for transport or medicines before they were discharged and privacy and dignity. this included bed spaces for those who were not mobile. • Video conferencing was used for bed meetings which Access and flow was primarily conducted from Northwick Park but had • Medical services were meeting the admitted referral to updates from all the Matrons at Ealing. This included treatment 18 week 90% target in all specialities other current bed availability by ward, and admissions waiting than cardiology and general medicine. in A&E. • Plans were in place for winter pressures although • There were seven declared medical patients that were additional beds had not been commissioned to open. outliers in June 2015. We found medical patient Escalation beds were sometimes put in the day room on outliers, being cared for on other wards including the cardiac ward if there was a shortage of capacity. The cardiac and care of the elderly wards. The trust service was also looking to utilise beds in a former executive had proposed a process called ‘breaking the maternity ward. cycle’ which would look at reviewing and recalibrating • Bed occupancy was above 85% on most wards, the services provided including trying to better prevent particularly the care of the elderly wards. Research patients in outlying beds where they were cared for on shows bed occupancy above 85% creates a higher risk the wrong ward. of compromised patient care. • Medical patients flowed with little delay between A&E or • Staff were concerned about the inflexibility of admission, through the AMU to a specialist ward. Very the schedule of ward phlebotomists. They commented few patients stayed in the AMU more than 48 hours and that wards were always covered in the same order no a high proportion were transferred or discharged within matter what the discharges or requirements of each six hours. However some staff seemed to think the ward were. This meant some wards were not reached target for transfer or discharge was five days. until 1pm and therefore their discharges might not have • There was fast tracking in place for patients who were ill their blood tests back in time to discharge the patient to the relevant specialist wards and patients could be the same day. • Nurses working on the acute medical units had access to ‘to take away’ (TTA) pre-packed medicines that could

40 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

be given to patients on discharge when the pharmacy • We found most complaints were being dealt with department was closed, however discharges were informally by staff on the wards but these were rarely usually planned so that discharge medicines were not recorded. Staff told us complaints were discussed at usually required out of hours. team meetings including any learning although not all meeting minutes we reviewed confirmed this. We saw Meeting people’s individual needs very few complaints leaflets with only a couple of wards • Translation services were available both via booked stocking them in public areas. interpreters and language line. Staff told us they booked • EH had an overall response rate to complaints of 85% interpreters when consent was required but also within 28 days. However there were very few formal used either their own staff or the patient's family for day complaints with six in a month for the inpatient wards. to day communication. We were told most were regarding communication. We • 5 South ward was described as a ‘dementia friendly requested examples of complaints responses but only ward’ and we observed some aspects met the individual received ones relating to sites other than Ealing needs of patients living with dementia such as clear Hospital. Staff told us actions were implemented bold colour coding between different areas, picture following complaints such as the activity room on a care signage on toilets and a dayroom for activities such as of the elderly ward. reminiscence and music which had led to a reduction in • Wards recorded informal complaints and compliments falls. Some of the signage was replicated in other wards. on paper. One ward had 14 records in 2015 so far which However, patients living with dementia were not varied from concerns about attitude of staff to wait specifically triaged to be admitted to this ward and times and communication. Actions to address the some aspects of the ward were concerning. This concerns were noted but some just stated ‘talked to included sofas with no arms plus a risk of sliding patient’ whereas others were discussed at nurse forward which meant a risk of a fall. The sofas were also meetings. placed facing away and below the nurses station which meant a staff member would have to either accompany Are medical care services well-led? them on the sofa or watch them very closely. • Senior staff at Ealing described having a lack of resource Requires improvement ––– to ensure care for people with dementia would meet the actions in the dementia plan for the trust as they only had one Clinical Nurse Specialist covering 300 beds Leadership for the inpatient medical services required across all care of the elderly sites plus dementia improvement. There was a lack of strategic direction for champions for each ward. They told us they received no EH and this was leading to uncertainty among staff. budget for meeting the dementia targets. Although the governance structure was new, there was a • Dementia care bundles were in place although some lack of cross site governance at department level and staff were not aware of them and we found the CQUIN there was a lack of communication and support between assessment was not always conducted in AMU. Overall some departments and the divisional leadership. There screening for dementia was 77.8% and assessment was was a lack of awareness or recording of some of the risks 93.7% against a target of 90% but this was across the in the division such as patient records and discharge. trust and not broken down by site. However, there was some good local governance and • There were specific leaflets for the type of ward patients teamwork at ward or department level although this was were admitted to. For example, the infectious diseases EH specific. and haematology ward had ones on blood conditions. • Those patients with complex needs including dementia Vision and strategy for this service or learning disabilities were flagged on each ward’s • Most of the staff we spoke with were concerned about electronic system so staff knew to review the patient’s what the future of Ealing Hospital was going forward records for their particular support needs. Learning from complaints and concerns

41 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

and were unaware of what the plans were in the short services and training rather than performance or term. There was no awareness from staff on the incidents. There were ward specific dashboards that infectious diseases and haematology ward what the monitored assessment completion, equipment checks vision for the future was other than recruitment. and medicines. • The strategy for medicine at the trust had very little • Medicine wide clinical governance meetings took place focus on Ealing. Senior staff at Ealing said there was no that purely focused on EH which included incidents, risk or little strategic direction from the division although registers, audits, national guidance, complaints, and they had their own ideas on an Ealing vision such as safeguarding. Staff were informed of actions in having a fragility unit or older persons rehabilitation summary form but with little to show what action was assessment centre (OPRAC), staff rotation between being taken in specific areas such as high falls rates or wards, a dementia matron and anti-falls equipment complaints trends. although this was only in drafted written form in a • A partial review of clinical governance was held at the notebook. The 2015/16 strategy for the division focused recent divisional clinical governance meetings to define on harmonisation, a move of gastroenterology for Ealing terms of reference with some brief performance reviews but we saw little evidence that these had progressed. such as incidents, appraisals, action plans and • The vision and strategy of the service did reflect some complaints. However it only had the divisional current risks such as nurse and consultant staffing levels leadership in attendance with no one at department and falls plus some reflection on inpatient performance level which was the case at previous meetings. There such as length of stay. had been some divisional monitoring of performance such as patients coming to harm, appraisals, delayed Governance, risk management and quality transfers, times of discharge and infection rates. measurement • We reviewed the medical services division risk register • The governance structure for medical services included which included areas we identified as concerns such as clinical, nursing and managerial leads at division and bed capacity, and staffing but not discharge or record department level with departments split into care of the completion. In addition, such risks were over two years elderly, emergency and acute pathways and specialist old with no date for completion. However, actions were medicine. However there were no clinical leads at in place to remedy the risks such as additional bed department level in place at the time of our inspection. capacity, recruitment and auditing. There were lead consultants for each speciality at each • Ward meetings varied. Some minutes we reviewed site. Most of the divisional and department posts were showed unstructured agendas that dealt with pertinent new due to the divisional structure only recently being issues at the time such as recent incidents or audit in place. The clinical director was part of the executive results, whereas others were structured but repetitive team. such as uniform and staff breaks policies. The former • Governance structures were partly in place in most of was more appropriate as there was clear review of the Ealing site but they were not joined up with the performance and feedback on incident learning which other acute sites and there was no or little feedback at the other meetings did not. Attendance was appropriate divisional level back to the departments at Ealing about with both senior and junior nurses in attendance. trust wide issues. Leadership of service • Performance management was mixed and not uniform. Staff in care of the elderly told us they only • All the staff we spoke with told us they were happy with monitored performance with emails giving current the support they received locally from their matrons, statistics. We received no minutes of meetings in consultants, service managers and heads of nursing at a haematology, infectious diseases or care of the elderly department level and that leads at this level worked so we were unable to ascertain how robust their together well. However as governance still occurred in a reporting and governance structures were. There had split way between Ealing and the rest of the acute sites, been one cross site meeting in diabetes and staff did not feel as supported by their divisional endocrinology. However this reviewed some current management.

42 Ealing Hospital Quality Report 21/06/2016 Medic al c ar e

Medical care (including older people’s care)

• Leadership accountabilities appeared to be unclear. For • Senior staff acknowledged staff were anxious due to not example, there was a deputy head of nursing and knowing what the future at EH was going to be. Staff general manager for care of the elderly services with job that had come from Northwick Park to take on descriptions that included having oversight of all the managerial roles were trying to be inclusive and trust sites providing care of the elderly wards. However, supportive to their staff and that this had helped the we were told the deputy head of nursing was not able to team dynamics. have oversight of sites other than Ealing, whilst the rest • Overall sickness was 3.5%. Staff told us the policy had of the sites were overseen by the Divisional Director of recently changed to improve sickness rates by Nursing. Staff told us they were confused by this introducing actions earlier in a sickness period. situation about what their line of escalation was and Staff engagement what their job roles fully entailed with fragmented communication and a lack of governance meetings at • Monthly staff forums took place with the executive team department level due to the lack of clinical leads. although very few of the staff we spoke with had • There was a lack of visibility of the executive team attended one. reported by staff other than on one of the care of the • Staff said there was a lack of communication at elderly wards despite the executive team stating they divisional level with information not coming down plus did regular walk rounds and weekly bulletins. some degree of having to do things only the way staff at • Clinical leads were in place at site level in each Northwick Park wanted. department but not at divisional level. This meant Innovation, improvement and sustainability consultants were feeding straight back to the divisional clinical director or medical director with any concerns. • A learning from practice meeting was scheduled for However a plan was in place to appoint clinical leads in November in specialist medicine which all staff were each department. invited to. • Cardiology investigation facilities at Ealing were good Culture within the service for a hospital of this size but it was noted that many of • There were some aspects of poor morale of staff on the the consultants had joint appointments at hospitals medical wards. Senior staff in care of the elderly said other than Northwick Park and the hospitals strategy for they perceived themselves to be ‘marginalised’ these services in the future was not made clear to us. compared to A&E and the acute medicine teams. • Most of the cost improvement programme targets were However, there was team spirit between the staff. not on target to be achieved.

43 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Safe Good –––

Effective Requires improvement –––

Caring Good –––

Responsive Requires improvement –––

Well-led Requires improvement –––

Overall Requires improvement –––

doctors across various grades, nurses, operating Information about the service department practitioners, healthcare assistants and allied health professionals. We reviewed 13 patient treatment and The number of surgical procedures at Ealing Hospital care records and spoke with 11 patients. We made between January to December 2014 was 9,742. Day observations of the environment, staff interactions and surgery was the main area of activity, at 53%. Emergency checked various items of equipment. surgical procedures contributed 33% of the total and the remaining 14% was elective surgery. General surgery was We undertook an unannounced visit to theatres and Brunel the main specialty, at 56%, followed by trauma and Ward on 4 November, where we spoke with three staff and orthopaedics (23%), urology (16%) and other specialties at two patients. 5%. Surgical specialties include; ear nose and throat (ENT), a full orthopaedic and trauma service with the exception of complex spinal surgery, maxillofacial and oral surgery, and ophthalmics. The vascular surgery department provides diagnosis and management of carotid disease, aneurysmal disease, peripheral arterial disease, critical ischemia of the leg and venous disease. Within the surgical directorate at Ealing Hospital, there are three wards, including; ward 7 South, which has 34 beds and is designated for trauma and orthopaedics, ward 7 North, which has 30 beds and cares for patients mainly with colorectal, upper gastrointestinal, urology and some gynaecology problems. Brunel day surgery ward has 22 beds. There are five operating theatres and a separate endoscopy department with ten beds, three cubicles and two procedural rooms. The six bed recovery department is managed by the Intensive Care Unit. Pre-admission assessment services were provided at the location. We visited all wards, theatres and endoscopy on 21 October 2015, during which we spoke with 40 staff including,

44 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Staff had the necessary skills and experience to ensure Summary of findings safe and effective patient outcomes and were supported appropriately. Patients needs were assessed, Patient safety checks in the Endoscopy department treated and cared for in line with professional guidance, were not taking place using the World Health under the care of consultants. The multidisciplinary Organization (WHO) Surgical Safety Checklist. In team and specialists supported the delivery of addition, the arrangements related to surgical treatment and care. Patients reported positively with instrumentation and availability of technical equipment regard to the quality and standards of care they received was not always ideal. from staff. Staff had a good knowledge of the issues around Where complaints were raised, these were investigated capacity and consent but there was lack of assurance and responded to and where improvements were that staff had received Mental Capacity or Deprivation of identified, these were communicated to staff. The Liberty Safeguard training. governance arrangements facilitated the monitoring of The surgical risk register did not always identify the risks, safety, patient outcomes and effectiveness of the specific location of risks. Dates for resolution of risks had service and information was communicated across all not always been stated. levels. The recovery area within theatres was not able to cope with the level of activity. Furthermore, the area used by children had not been designed or planned to take into account their needs. Patient surgical outcomes were monitored through audit and required improvements had been noted for hip fracture patients and those having an emergency laparotomy. The hospital audit results were mixed when compared with England averages. Some national audits were not completed and some that were had data missing in parts. Referral to treatment times were not being met in some surgical specialties, such as, general surgery, trauma and orthopaedics, urology and oral surgery. Theatres were not always effectively utilised and operating sessions started and finished later than planned, which impacted on patient discharges. Staff reported positively on their immediate line managers and demonstrated a commitment to the delivery of high quality patient care. Despite this, staff had been affected by recent changes following the merger of trusts and were struggling to understand the future direction of the service at this location. Directorate leaders were developing the surgical directorate strategic aims and demonstrated a commitment to delivering high standards across the surgical locations.

45 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

cumulative results over time and also year to date. Are surgery services safe? Results for ward 7 North indicated scores of between 80% and 100% for the patient safety quality indicators Good ––– year to date. • There had not been any surgical Never Events at the We rated safety in surgery as good. There were effective Ealing Hospital in the previous year up to the time of our processes for reporting, investigating and learning from inspection: “Never events are serious, largely incidents. Staff were open and honest with people when preventable patient safety incidents that should not things did not go as expected. Patient safety was prioritised occur if the available preventative measures have been and there were arrangements to manage patient risks and implemented.” to provide additional interventions when needed. • We reviewed evidence in the theatre department, which indicated the sharing of information with regard to a Clinical staff adhered to infection prevention and control never event which occurred on another location within best practices and adhered to professional guidance the trust. We saw a full review of the situation had been around medicines. conducted and the action taken to minimise Whilst there were areas of clinical staff vacancies, the reoccurrence. A staff log had been completed to staffing arrangements ensured the safe delivery of patient indicate when staff had read the revised policy, which treatment and care. There were enough medical and had been written in response to the event. Staff had also nursing staff to keep patients safe at all times. attended half day governance study sessions, during which there had been shared learning related to the Staff received mandatory safety training. Staff handovers never event. There was an awareness within other were well managed with key issues identified, recorded and nursing areas of the never events which occurred on actioned to ensure patients who were unwell were other sites. monitored and supported. • The Serious Incident Framework 2015/16 describes The recovery area did not have sufficient capacity to enable Serious Incidents (SI) in health care as adverse events, all patients to be recovered following their surgery. where the consequences to patients, families and carers, staff or organisations are so significant or the The World Health Organization (WHO) Surgical Safety potential for learning is so great, that a heightened level Checklist had not been implemented in the endoscopy of response is justified. Between August 2014 and July service. Surgical instruments were not always readily 2015, there were seven reported SI’s in the surgical available. directorate at the Ealing Hospital site. These included Incidents three pressure ulcers at grade three, two further pressure ulcers which met the SI criteria, one surgical • Nursing and medical staff were aware of the processes invasive procedure and a cardiac arrest, which followed to follow in order to report adverse incidents or a short time after the removal of a central line. The concerns. Staff who spoke with us understood their patient safety and quality indicator for ward 7 North responsibilities to raise concerns, to record safety showed no reported serious incidents for the year to incidents, concerns and near misses, and to report them date. There was a full investigative process for SI’s, internally in order that they could be investigated and which included root cause analysis, conclusion and acted upon. shared learning. We do not have comparison data • Safety goals had been set with respect to a range of sufficient to indicate incident reporting rates in surgery indicators. These included, safety around medicines, the but trust wide there is a lower level of incident reporting completion of patient safety checks, staffing levels and per 100 admissions at 7.1 than the England average at safety related training. Targets were rated using a traffic 8.4. light system of red, amber and green, and a • There was a multidisciplinary medicines safety forum performance dashboard was produced for each area. across all trust sites. Medicines incidents were discussed This enabled staff to see the monthly performance and

46 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

at this forum, and learning was shared across staff appropriate. We were informed by the surgical pharmacy and nursing staff in a variety of ways, such as directorate lead that M&M meetings had been increased emails, handover meetings, medicines bulletins, and took place every two weeks in each directorate. information published on the intranet. They told us soft intelligence, along with the M&M • Staff were open and honest with relevant patients or process enabled identification of issues and action to be relatives when serious incidents had occurred. We taken. For example, we were made aware of action reviewed written correspondence in which the relative taken in response to the death of four patients following of a patient was invited to attend a meeting with a specific procedure over a period of eight months. relevant staff in order to be appraised of the outcome of • Our review of minutes from M&M meetings indicated a SI investigation. that information discussed fed into service • Nursing staff reported being made aware of incident improvement and learning from specific cases was investigations and such information was shared at made clear. For example, we saw a formal presentation monthly ward meetings and sisters' forums. Two for the joint surgical and anaesthetic mortality and members of nursing staff described independently the morbidity meeting for emergency surgery. There was learning and actions taken from one SI that had evidence of discussion of the patient treatment pathway occurred on ward 7 South. and various complications, along with interventions and • From our discussions with a wide range of nursing staff, root cause analysis. there was a good understanding about being open and Safety thermometer honest with people when things had gone wrong, although Nursing and medical staff had a variable level • The NHS Safety Thermometer scheme had been used to of awareness of the term ‘Duty of Candour’. This sets out collect local data on specific measures related to the premise that as soon as reasonably practicable after patient harm and 'harm free' care. Data was collected becoming aware that a notifiable safety incident has on a single day each month to indicate performance in occurred, a health service body must notify the relevant key safety areas, such as hospital acquired pressure person that the incident has occurred, provide ulcers, patient falls and urinary tract infections related reasonable support to the relevant person in relation to to having a urinary catheter. This data was collected the incident and offer an apology. electronically and a report produced for each area. • We found that staff adhered to the principles of the duty • At Ealing Hospital the prevalence rate of pressure ulcers, of candour. We reviewed an example of a written patient falls and catheter related urinary tract infections communication sent to a patient, in which they were remained low during the period of June 2014 to June invited to meet with representatives of the trust in order 2015. We observed results displayed on ward areas and to receive feedback with regard to an adverse incident. saw for example, in the year to date, there had been We noted the letter contained an apology. eight patient falls on ward 7 North, none of which had • The number of surgical site infection rates following hip resulted in the declaration of a serious incident, such as replacement surgery at Ealing Hospital was reported to a fracture. There had been two hospital acquired us as having been 16 for the period October to pressure ulcers graded as two to four year to date on December 2014 and six between January and March this ward. Of these, none had been declared as 2015. The number of patients who developed a surgical avoidable. There were no reported urinary catheter site infection following knee replacement was reported related urinary tract infections on ward 7 North and no to have been 29 and 28 across the same periods patients who had developed a deep vein thrombosis. respectively. There had not been any incidents in these categories on • We noted from the terms and reference of the Mortality Brunel Ward. and Morbidity (M&M) meetings that information was to • Care bundles were in place to support staff in the be reported to the Divisional Governance Meetings and delivery of care and for managing such areas of risk agreed specific recommendations and findings would associated with reduced mobility, urinary catheters and be escalated to the Clinical Directors, the Divisional falls. Clinical Director, Divisional Manager and Divisional Head of Nursing for Surgery or Executive meetings where

47 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Cleanliness, infection control and hygiene • We saw staff following to safe practice with regard to isolating people who had been identified as having an • In surgical wards, operating theatres and endoscopy infection. Signage was in place on the doors to isolation areas, we found the environments were clean or were rooms to alert anyone visiting or staff entering of the being attended to by domestic staff at the time of our actions to be taken. visit. Standards of cleanliness and hygiene were • We noted on ward 7 South, which was a mixed trauma maintained by dedicated staff as part of a service level and orthopaedic ward, that many of the patients were agreement with an external provider. Monitoring of from general surgical specialties. Potential infection standards was carried out by the service provider, for risks were minimised as ‘clean’ elective surgery patients example the supervisor inspected theatres daily and were separated pre-operatively from people requiring staff advised the wards were checked weekly. We emergency surgery. reviewed monitoring results for April and May 2015 and • Patients' records reviewed confirmed they had been noted a 98% score with regard to cleanliness in theatres. screened for Meticillin-Resistant Staphylococcus Aureus • Domestic staff had been provided with guidance on (MRSA) during pre-assessment or as soon after required cleaning standards, instruction on the admission as possible, where they had been admitted frequency of cleaning and procedures. National colour as an emergency. We noted from patient safety and coded cleaning equipment was provided to domestic quality monitoring that MRSA screening was reviewed staff and they were seen to carry out their duties safely, on an on-going basis. Results for ward 7 North indicated wearing personal protective equipment (PPE). MRSA screening to be 100% year to date. On ward 7 Information was displayed on wards about the South MRSA screening had been 98% up to July 2015 frequency of cleaning, which was based on a risk and on Brunel Ward compliance with screening was assessment. 99%. • We reviewed a number of infection control policies and • Patients received information in the pre-operative found up to date and reliable information to support phase about showering and hair removal, hand staff in the prevention and protection of people from a jewellery, artificial nails and nail polish. Checks were healthcare-associated infection. We saw that made as part of the patient’s preparation for theatre and staff followed safe practices as outlined in the respective prior to escorting to theatre. Where specific preparation policies, such as wearing PPE, dress code and disposal was required for a surgical procedure, information was of clinical waste. In addition, we saw that staff had provided by staff. ensured items of equipment used by patients, such as • Theatre staff followed NICE guidance with respect to commodes, blood pressure cuffs and infusion devices theatre wear and dress code when leaving the operating were clean and labelled as such. area. They observed best practice during each stage of • Nursing staff confirmed that there were link nurses for the intraoperative phase including hand infection control and that these individuals had a decontamination, application of surgical drapes, sterile responsibility for attending meetings and cascading gowns, gloves, and antiseptic skin preparation. information and training to staff. The monitoring of staff • Patient care records reviewed by us demonstrated compliance with infection prevention and control where staff had followed the specified procedures standards was also part of their role. This included hand necessary for the safe insertion and maintenance of hygiene compliance. For example we saw, on the quality intravenous devices. Staff had recorded when devices board presented on ward 7 North, a hand hygiene had been inserted, monitored the site of insertion and compliance rate of 100% for October 2015. In theatres recorded when they had been removed. On-going we saw a compliance rate of 97%. compliance with the safety indicator related to • There was access to adequate hand washing facilities peripheral cannulas was noted to be 98% for ward 7 and decontamination hand gel was readily available at North in July but no results had been submitted for the point of care. We observed all nursing, medical and ward 7 South. allied health professional staff washing their hands • Performance data for surgical wards did not contain immediately before and after every episode of direct information about infection rates. However, contact or care. we reviewed information displayed in ward 7

48 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

South,which indicated there had not been any • We observed that staff working on wards and in theatres Clostridium Difficile or MRSA on ward 7 South for the were following safe arrangements for managing the year to date. Similarly there had not been any reported different types of waste and clinical specimens in order cases of either infections on ward 7 North or on Brunel to keep people safe. Ward. • We looked at equipment check records. Blood pressure • We saw that all staff observed bare below the elbow machines, infusion devices and hoists had evidence of practice on the wards. safety checks having been completed. • Surgical equipment including resuscitation and Environment and equipment anaesthetic equipment was available, was fit for • Wards ranged in size and layout but were noted to be purpose and had been checked in line with professional set out in a manner which ensured people were safe. guidance. However, surgeons raised concern with us Wards were accessed by staff using a swipe card or that there was inadequate stock of some “bread and buzzing through to the reception in a visitor’s case. butter” items of equipment, such as endoscopic • The operating theatre department had five separate gastro-intestinal cartridges, and they were frequently theatres, with associated anaesthetic rooms and the asked by theatre staff to “make do” with an alternative. required separate clean preparation and dirty areas. • Checks of essential theatre equipment had been There was Laminar air flow in three of the theatres. undertaken and there was access to emergency items of • The six bedded recovery area was managed and staffed equipment. There was sufficient supply of drapes, by the Intensive Care Unit. Theatre staff reported facing gowns, suction and other items used for the safety of a "bottleneck" regularly as two or three of the recovery patients in theatres. beds were used by High Dependency Unit patients. This • Single use equipment was available on wards and in resulted in patients having to be recovered in theatres. theatres. Sterile surgical instruments used in theatres Furthermore, children were recovered in the same area were processed at a centralised centre external to the as adults. hospital. Surgeons reported inadequate supply of • The endoscopy department had not achieved Joint other equipment items, such as retractors and advised Advisory Group (JAG) accreditation as a result of a that sets came back from the decontamination unit number of factors, for example, not being able to meet incomplete. During our visit we found one item of ventilation requirements in the endoscope instrumentation missing from the tray inspected before decontamination room. We found that staff were having the start of surgery. Such problems resulted in staff to keep the fire exit door open to facilitate ventilation having to locate and open additional sets, which and improve the ability of staff to work there. (JAG had delay and cost implications. This incident had been Accreditation is the formal recognition that an reported via the Datix process and we saw this on formal endoscopy service has demonstrated that it has the documentation provided. competence to deliver against the measures in the • There were items of equipment available in theatres for endoscopy Global Rating Scale (GRS) Standards.) the safe positioning of individuals who were outside of • A number of risks related to endoscopy services had standard weight ranges. Operating tables were suitable been identified on the risk register, although it was not for individuals up to the weight of 250 kilograms. clear which locations the risks related to. Actions had Medicines not always been identified and there were no time lines stated for resolution. • Nursing staff informed us that pharmacists and • Within endoscopy, each of the two procedure rooms pharmacy technicians visited the wards daily Monday to had an endoscopic stack. Staff told us the stacks were Friday in order to review all prescriptions, including new serviced by the electrical engineering department, and admissions and those who were to be discharged. they held the records of such actions. The endoscopes Medicines cupboards and ‘patient pods’ used for were serviced under a service contract by the company patients' own medicines were topped up daily. and labels were attached to indicate when the service • We checked the process for obtaining, prescribing, had taken place. recording, handling, storage and security, dispensing, safe administration and disposal of medicines on wards

49 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

and in theatres. The arrangements for managing • Our review of patient records demonstrated that medicines and medical gases ensured people were kept allergies had been clearly documented in patient safe. Medicines were stored safely in lockable cabinets, prescriptions. Prescription records were clear and which were secured to a wall when not in use. Medicines evidenced the different routes, times and frequency of cupboards were locked and only accessible through a medicines to be given, as well as those that were secure keypad door. Fridge temperatures for storage of prescribed on an as required basis. temperature controlled medicines had been carried out • We observed nursing practice around the protocols for and action taken when the range was outside safe administration of controlled drugs (CD) as per the levels. Nursing and Midwifery Council – Standards for Medicine • In one anaesthetic room, we noted the drugs for the Management. Staff followed procedures correctly and whole surgical list for the day had all been prepared in ensured that all necessary safety checks had been advance. This was not best practice and posed risks of carried out prior to the patient being administered the drug errors arising. Otherwise medicines used in the CD. anaesthetic room and theatres were seen to be • Checks on the ward and theatre CD registers prepared safely, with labels attached to syringes and demonstrated safe record keeping with regard to all checks were undertaken prior to administration. aspects of CD management. Medicines given to patients were recorded on • The medicines department had undertaken regular anaesthetic charts and prescription records in the audit of the management of controlled drugs. The audit theatre area. results for Ealing Hospital (June 2015)indicated that • Staff on wards wore red tabards indicating they were adherence to CD standards was above the trust target undertaking medicines rounds and should not be and achieved 97%. It was noted this was a slight interrupted. We saw that staff took time to check the improvement on the previous quarter results. A number prescription chart when preparing medicines and prior of surgical areas were noted to be 100% compliant, to administration to make sure that the patient was including main theatres, recovery, endoscopy and correctly identified. theatres one to seven. Where corrective action was • We noted in the minutes of the Ealing Hospital required this had been defined, with responsible Medicines Safety Group held on June 15 2015, errors persons identified and agreed timelines for resolution. which occurred in the surgical directorate had been • The use of summary care records (SCR) had been discussed and reviewed. Information provided had also implemented at Ealing hospital to assist with the included associated guidance, which had been completion of medicines reconciliation, which both communicated by way of patient safety alerts. pharmacists and pharmacy technicians were trained to • There was evidence of good antibiotics stewardship. carry out. The medicines management technicians were The antibiotics section of the Ealing hospital drug chart also trained on conducting medicines reconciliation had been designed in such a way that it ensured that a and they were accredited via London Pharmacy doctor reviewed the need for the antibiotic after three Education and Training. days, and again after seven days. The indication of the • Following the National Patient Safety Agency (NPSA) antibiotic was required on the drug chart, as well as the alert on missed doses, the trust had implemented a name of the staff member from the microbiology team number of strategies in an attempt to manage and that was involved in the decision to prescribe the reduce the number of missed doses. For example, pink antibiotic. Gentamicin and vancomycin both had their stickers were placed in patient notes to communicate own drug charts, which prompted the clinicians to take the dose missed and the reason for the omission; the relevant drug monitoring levels before the medicine medicines safety bulletins; and shared learning at was continued. Point prevalence studies (an assessment meetings. of the use of antibiotics and level of compliance with the • Overseas adaptation nurses who were awaiting their antibiotics guidelines) were conducted every six nursing registration pin explained how they had months, and the outcome data was then fed back to the undertaken a drugs calculation test and, once they had antibiotics stewardship group and the Drugs and their pin, they would complete competency based Therapeutics Committee. training related to medicines management.

50 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

• We checked the arrangements for storage and • We were told by a matron that spot checks were management of substances, which came under the undertaken on patient records in order to assess quality control of substances hazardous to health (COSHH). On of records completion. We did not see any formal ward 7 South, nursing staff did not know when checks documentation to support this. had been done on the COSHH cupboard. Matron Safeguarding advised a risk assessment had been carried out on the COSHH arrangements last year on ward 7 North. • A formal safeguarding policy was provided to staff, which outlined the underpinning principles, Records responsibilities and the governance and reporting • We found from our review of patient treatment and care structures. This was found to be accessible on the records that a standard approach was used for these, hospital intranet. although there was a slight variation in day surgical • We noted from minutes of the adult safeguarding documents when compared with inpatient records. Care meetings that there was multidisciplinary plans were not individualised but were generic, covering representation. Discussion covered a range of relevant a range of nursing assessment related to activities such matters, such as domestic violence, training, dementia, as nutrition, washing and dressing, sexuality and body mental capacity and deprivation of liberty safeguards. image, sleeping, mobilising and disabilities. • Nursing staff advised they were required to complete • Documentation completion by nursing, surgical levels one and two safeguarding training on-line. Face to staff and allied health professionals was mostly face training was provided for those who were required completed to a good standard. Information was legible to have level three training. An overseas adaptation and enabled staff to understand and deliver the nurse told us they had not completed any safeguarding required treatment and care to their patients. vulnerable adults training. Despite this they had a good • Risk assessments were part of the patient treatment and knowledge and understanding around the subject. care record and included pressure areas, nutritional, • There were no lead nurses for safeguarding on ward 7 patient handling, falls and bed rails assessments. South; however, staff confirmed there was access to the Information recorded assisted nursing and other staff to safeguarding team. In addition there was access to the understand what was expected of them in terms of Caldicott guardian based at Northwick Park Hospital. supporting the delivery of care; however, there was no • Safeguarding alerts were said by a member of nursing additional information to indicate patient’s specifics staff to be added to the electronic information system. wishes, preferences and choices. Records were mostly • Training rates for nursing staff for safeguarding adults accurate, complete, legible, up to date and stored level two were 100% on ward 7 North. On Brunel Ward it securely. was 85.7% and in theatres there were three staff out of • Essential information to keep people safe had been 28 (10.8%) identified as requiring safeguarding adults identified and acted upon, for example, the use of bed training. rails or specialised mattresses. Information about • In our discussion with clinical staff they were able to this was communicated to staff in the care records and demonstrate their awareness of safeguarding and reinforced at handover between shift changes. understood their responsibilities to adhere to • Where patients were having their fluid intake and output safeguarding policies and procedures, including acting monitored, we found that 80% of the charts for on possible concerns. recording such information had been completed fully. Mandatory training The totalling of intake and output was missing in two out of 10 records reviewed. • Nursing and theatre staff confirmed there was an • Where people had attended pre-operative assessment, expectation to undertake mandatory training and that the information gathered at this appointment had been staff had to take responsibility for completing this. recorded on the nursing record and was made available Subjects included for example; Infection prevention and for the subsequent admission. control, health and safety, manual handling and resuscitation.

51 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

• Ward 7 South staff reported finding it difficult to Competencies for Recognising and Responding to complete the required mandatory training due to ward Acutely ill Patients in Hospital (2009) and the Royal activity demands. Mandatory training compliance was College of Physicians; Standardising the Assessment of reported to be 46% year to date on ward 7 South. In Acute Illness Severity in the NHS (2012). We noted staff theatres we noted 69% of staff had completed the completed the required observational tool, known as required training and the figure was the same on Brunel NEWS. Resulting scores from this enabled staff to alert Ward. A compliance rate of 87% had been achieved on medical staff where a patient’s condition was ward 7 North. 91% of staff had completed training deteriorating. We saw evidence in patient notes of the in infection control, 97% in conflict resolution, 89% responsiveness of medical staff in such a situation and in equality, diversity and human rights and 85.29% the actions taken to manage associated risks to the in resuscitation. patient’s wellbeing. • Compliance with the completion of the NEWS was Assessing and responding to patient risk monitored and we saw for example on ward 7 South • Our review of patient records demonstrated staff had year to date a compliance rate of 93%. This ward did completed comprehensive risk assessments with less well in May 2015 (83%) and September 2015, (75%). respect to falls, nutritional needs and venous • In conjunction with the NEWS, staff completed a specific thromboembolisms (VTE). In addition, patient reporting tool, known as ‘SBAR’. This recorded details assessment included identification of potential risks about the situation, background details about the associated with having a general anaesthesia. patient, their assessment, such as blood pressure and • Within the patient records we reviewed we were able to respiratory rate. The final section related to see evidence that staff were complying with the recommendations, for example, the need for immediate National Institute for Health and Care Excellence (NICE) attention. quality standard related to venous thromboembolism • Nursing staff reported the Critical Outreach Team as (VTE) risk assessments and management. We found that being responsive when their advice or interventions all patients, on admission, had received an assessment were required. of VTE and bleeding risk. Where interventions were • Staff followed a sepsis pathway for the management of required, these had been acted upon, including the use patients whose condition met the criteria. of prophylaxis medication and support stockings. • We noted from patient records and observed staff Compliance with VTE checks had been monitored and undertook two hourly 'comfort rounds', as they were we saw a 100% compliance rate year to date on ward 7 known. These provided an opportunity for nursing staff North, Brunel Ward and in theatres. to check the status of the patient, their comfort and • Pre-operative assessments included a comprehensive wellbeing and to update risk assessments accordingly. review of the patients previous and current health • We observed theatre staff following the ‘Five Steps to problems and needs and physical assessments had Safer Surgery’, which included team brief, sign in, time been carried out in line with guidance on pre-operative out, sign out and debrief. Staff confirmed the ‘Brief’, assessment for both day case and inpatients. which was the first part of the 5 steps to safer Surgery, • We noted that risks were managed positively through World Health Organization (WHO) Surgical Safety the appropriate use of interventions. For example, this Checklist commenced at around 8:15am in every included ensuring high risk patients who needed theatre. Theatre Staff were all aware that an operating surgery were not admitted as a day case. Where list would not commence unless a ‘Brief’ had taken required, patients were seen by the tissue viability nurse place. Surgeons and anaesthetists were said to arrive a in order to ensure potential risks to their skin were few minutes later than 8:15am, as they were busy seeing managed effectively. and consenting patients in the theatre admissions area. • Ealing Hospital had a patient observation and The consequence of this was that the start time of escalation policy, which was noted to reflect the operating list was later than planned, but there was a guidelines from the National Institute of Clinical Excellence (NICE) CG 50, the National Patient Safety Agency (NPSA) (2007), the Department of Health;

52 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

firm understanding that conducting the ‘Brief’ was staff were used. We noted from the information three mandatory. The process was led by the operating agency nurses, 62 bank nurses and 20 bank healthcare surgeon and with the full attention of the entire team in assistants had been used in the month of September theatres. 2015. • Whilst we did not witness if the final stages of the • Rotas provided to us for wards 7 North and South process, ‘Sign Out’ or ‘Debrief’ was carried out, we noted indicated the arrangements for staff cover, with balance from the compliance monitoring data displayed in of skill mix across day and night shifts. We saw there was theatres on the notice boards a good standard of a band six nurse taking charge when a more senior practice and the overall performance was well over 90%. nurse was not on duty. The process identified as not yet fully embedded in • We observed on our visits to the wards the expected and practice was the ‘Debrief’. We were told that this was actual staffing levels displayed for day and night shifts. due to the fact that lists over ran. The theatre and Staffing levels were noted to match the requirements on general manager were aware of this and recognised the the day of our visit on ward 7 South but the staffing on need to work with the teams to embed this element. ward 7 North had been depleted by sickness of one • We found in our review of patient records evidence of healthcare assistant. On the Brunel Ward staffing levels each stage of the five steps of safety mostly having been matched expectations. undertaken. • We were made aware of high vacancy rates by nursing • In the Endoscopy department, there was no evidence of staff; for example, on ward 7 South there were nine band a WHO Safety Checklist, and on further investigation five nurse vacancies. These posts had been advertised with the Endoscopy Manager and Consultant surgeon and four or five of them were expected to be filled once this was confirmed. professional pin numbers had come through for the • There was access to advice following discharge from overseas adaptation nurses. On ward 7 North, the nurse Brunel Ward. We reviewed the information which was vacancy rate was at 20%, with a ratio of one nurse to provided to patients and found there were details of nine patients achieved with the staffing arrangements in who to contact and the telephone number for the first place. 48 hours after leaving hospital. • In order to ensure safe staffing levels, there was a • American Society of Anaesthesiologists (ASA) fitness reliance on contracted staff undertaking extra hours as assessments for anaesthetics were completed on all ‘bank staff’ in their own time. The ward also used two patients prior to surgery and those classified as an regular agency nurses, one for days and one for nights. emergency were identified accordingly. Induction and local orientation was completed for agency staff. Nursing staffing • Staffing numbers and skill mix was cited as a problem • Staff told us a safer staffing tool was used periodically to on ward 7 South and in particular the protracted assess the required staffing levels and skill mix. This was recruitment process and needing to have cover for said to have been completed most recently as July sickness signed off, which was said to be time 2015 on ward 7 North. The results had indicated acuity consuming. as being higher in the last two weeks than the first half • The interim theatre manager advised us that staffing of the month. Information from the tool was said to establishment had been reviewed and reductions had have been sent to the auditor and had resulted in subsequently resulted. Four staff were allocated to each improved staffing, reducing the ratio of patients to nurse theatre (previously five), and they provided the required from one to 10, down to one to nine. Performance roles to support the surgeon and anaesthetists. There indicators for ward 7 North demonstrated a nurse to were 12 vacancies at the time of our visit but patient ratio of 1:8.6 year to date. recruitment was reported to be difficult as a result of • We reviewed a staffing report for ward 7 North, which “bad press” around the decommissioning of services. required completion on a daily basis. The information Cover for these vacancies was achieved by the use of reported planned staffing by registered nurse and agency staff, and such staff were required to complete a healthcare assistant per shift and where bank or agency local induction and orientation.

53 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

• There were 16 staff working in the endoscopy Major incident awareness and training department, which included two administrative staff. • A major incident protocol was available to staff to One vacancy remained at the time of our visit. access and we noted actions to be taken were displayed • The handover of patient information took place at each on ward 7 South. We saw action cards were available to shift change and included details about each patient staff in theatres. condition, specific tests or investigations needed and • We reviewed the protocols for deferring elective activity their progress. to prioritise unscheduled emergency procedures and Surgical staffing found there was a formal process for staff to adhere to. This included stopping elective work if there was a need • Surgical staffing skill mix at Ealing hospital was made up to open a second emergency theatre. as follows: 30% were consultant grade staff, 18% middle career, that is those with at least three years as a senior house officer or a higher grade in a chosen specialty. Are surgery services effective? Specialist registrars made up 26% and there were 24% junior doctors in foundation years one or two (F1/2). Requires improvement ––– • There was a consultant on duty during day time hours and on-call at nights. Surgery was consultant led. The hospital audit results were mixed when compared with • The FY1 and FY2 doctors (Foundation Year 1 and 2) were England averages. Some national audits were not assigned to a consultant and an area of surgery, such as completed and some that were had data missing in parts. general surgery or orthopaedics. In our discussion with a FY2 doctor they perceived themselves to be very well Patient surgical outcomes had also been monitored by supported by the specialist registrar (SpR) and local audit. Patients with a hip fracture were not always consultant surgeons and anaesthetists, all of which admitted to orthopaedic care within four hours and surgery were said to be easily accessible. was not always performed on the day of admission or the • There was full surgical medical cover during the day. A following day. general surgical SpR was resident at nights , whereas the The National Emergency Laparotomy Audit for 2015 trauma and orthopaedic SpR was home based and on indicated four areas where patients care was not met. call. • Surgical staff shift changes enabled the communication Patients having non-elective surgery stayed on average of relevant patient information so that on-going slightly above the England comparator, at 5.4 days. Length treatment and care could be delivered safely. of stay was higher for trauma, orthopaedics, and urology. • We observed ward rounds taking place on each area For patients having non-elective general surgery the length visited and there was a doctor’s presence on each ward. of stay was less than the England average. • Information provided to us indicated the speciality and Staff had a good knowledge of the issues around capacity frequency of locum surgical staff. For example we noted and consent but we did not have assurance that staff had a whole time equivalent consultant for head and neck received Mental Capacity or Deprivation of Liberty was being used until there was agreement on the Safeguard training. service model and a substantive post was advertised. We were unable to tell from the information entered on Patients had been assessed, treated and cared for in line the record the number of locums used by location. A with professional guidance. Consultants led on patient care consultant locum was on ward 7 South when we visited. and there were arrangements to support the delivery of They were very ‘hands on’ and knew their patients in treatment and care through the multidisciplinary team and detail. This individual commented positively on the level specialists. of patient safety. The majority of patients reported effective pain management and monitoring.

54 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

The nutritional needs of patients had been assessed and theatre 5 was used for emergency surgical patients and patients were supported to eat and drink according to their patients were booked via the completion of a proforma needs. There was access to a dietitian and the speech and and assessed and prioritised by an anaesthetist. The language therapy team. Special medical or cultural diets classification was done at the time of the decision to were catered for. operate and when the theatre was booked. The correct classification was supplied to the theatre co-ordinator Staff caring for patients had undertaken training relevant to when the patient was booked so an appropriate priority their roles and completed competence assessments to was assigned to the case. The classification was ensure safe and effective patient outcomes. Staff received recorded in the patient’s case notes. an annual performance review and had opportunities to • We spoke with an anaesthetist about accessing and discuss and identify learning and development needs following guidelines from the Association of through this and supervision meetings. Anaesthetists of Great Britain and Ireland (AAGBI). We Evidence-based care and treatment were shown an example of the guidance, with regard to managing Malignant Hyperthermia. This was held on • Our observational checks of patient records confirmed the individual’s mobile phone and we were told this was compliance with NICE QS66 Statement 2: Adults common practice. There was access to the required receiving intravenous (IV) fluid therapy in hospital are medicines in the event that such a case occurred. cared for by healthcare professionals competent in • We found there was an enhanced recovery programme, assessing patients' fluid and electrolyte needs, led by the orthogeriatrician and supported by a trauma prescribing and administering IV fluids, and monitoring nurse co-ordinator, which ensured the appropriate patient experience. We saw that intravenous fluids and pathway was followed by patients who received medicines had been prescribed by a doctor. Records of treatment and care following a fractured neck of femur. administration had been completed and recorded on A discharge co-ordinator was responsible for liaising prescription charts and fluid balance forms. with occupational therapists and physiotherapists with • Patients who were assessed to be at risk of VTE had regard to patient recovery and planning for discharge been prescribed and administered with VTE prophylaxis home or for on-going care. in accordance with NICE guidance. • Professional guidance was followed with respect to • Nursing and medical staff assessed the needs of the recording and management of medical device implants. patients on admission and throughout their Data was submitted to the national joint register, hospitalisation. Treatment and care was planned and subject to patient agreement. delivered in line with evidence-based, guidance, • Pre-operative tests were undertaken in accordance with standards and best practice. Monitoring of patient safety best practice guidance. Pre-operative assessment outcomes enabled the surgical directorate to assess included assessment of patient’s physical well-being such standards were being delivered. and staff provided advice with respect to optimal fitness • We did not see any evidence to suggest discrimination for surgery. This included advice related to diet, on grounds of age, disability, gender reassignment, medicines, mobility and instructions regarding pregnancy and maternity status, race, religion or belief preparation for surgery. and sexual orientation in making care and treatment • Steps were taken within the operating theatre to decisions. minimise the risk of patients developing a surgical site • Technological equipment was used to monitor patient infection. We saw attention was given to the correct well-being and enhance the delivery of effective care procedures of preparing the patients incision site and and treatment in theatres, recovery and on wards. post-operative wound dressings. • We found the surgical services were managed in • The post-operative recovery of patients focused on accordance with the principles outlined in National supporting them to be as mobile as possible and to Confidential Enquiry into Patient Outcome and Death regain their independence. The resumption of normal (NCEPOD) classifications around access to emergency eating and drinking was encouraged where appropriate theatres and the Royal College of Surgeons (RCS) and unless a clinical indication, drips and urinary standards for unscheduled surgical care. For example, catheters were avoided.

55 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

• We noted there was a programme of audit which set out • Where patients required intravenous fluids these had the areas of focus and expected completion date of been prescribed by the doctor. We saw that fluid March 2016. The anaesthetic audit at Ealing Hospital balance charts were provided and used to monitor the included Procedural Sedation in Adults, Sprint National patient input and output. Anaesthesia Project (SNAP) and a medical records audit. • Patients were not fasted for lengthy periods prior to Orthopaedics were auditing compliance with British theatre, although it was noted in day surgery (Brunel Orthopaedic Association, and BOAST 1 Version 2 Neck of Ward) there were times when patients did not go to Femur (NOF) Guidelines adherence, medical records, theatre as early as expected and therefore they went and the National Joint Registry (NJR - hip, knee and some time without food. ankle replacements). Other general surgery audits • Anti-nausea medicines had been prescribed for patients included the National Comparative Audit of Patient who experienced nausea and vomiting after surgery. Blood Management in Surgery, National Inflammatory • There was access to dietitian services pre and post Bowel Disease. operatively, along with support from the speech and language therapy (SALT) team for patients who had Pain relief difficulties in swallowing. Although dietitian's were not • We found from our review of patient records, which available on-site at weekends, there was guidance included the completion of comfort rounds and related to nutritional feeds on the intranet. observational tools, patients had their pain assessed. A Patient outcomes scoring system was used to rate the level of pain. There were pictorial signs for expressing pain available to • Audit results for the service were mixed when compared individuals who had learning disabilities or a cognitive with England averages - some better, some worse. They impairment. were not consistently better than average results for • Staff said that they had access to the pain team when England. Some national audits were not completed and required. This included anaesthetist advice at some that were had data missing in parts. weekends. We found there was consideration of the • The service was reviewing the effectiveness of care and different methods of managing pain, including patient treatment through local audit and national audit. The controlled analgesia pumps. National Bowel Cancer Audit results for Ealing Hospital • The fractured neck of femur analgesia pathway in 2014 indicated a good case ascertainment rate of included use of the fascia iliaca compartment block for 96%, slightly above the England average of 94%. The pain relief, where patients were suitable. location did better than the England average for having • We observed and heard staff asking patients if they had computerised tomography (CT) scans reported, 93.9% any pain. We also saw them act on this where patients compared with 89.3%. Areas where they scored slightly indicated they had pain. Pain relief, including controlled less than the England average related to patients being drugs were only administered after nursing staff seen by a clinical nurse specialist (84.9%) and patients checked patient details against their prescription. being discussed at the multidisciplinary team (98.5%). • Patients reported mixed experiences of having their pain • The Lung Cancer Audit results for Ealing Hospital for needs addressed, although the majority were satisfied 2014 indicated that 98.5% of patients had been with their pain management. However, one patient told discussed at a multidisciplinary meeting, which was us they had waited for pain relief as staff were busy. above the England and Wales average of 95.6%. The Another patient said whilst they had been given pain percentage of patients receiving a CT scan prior to a relief, staff did not check if this was effective or not. bronchoscopy was less than the England and Wales • Pre-operative assessment included a review of existing average at 82.4%, compared to 91.2%. pain and current treatment for this. • Ealing Hospital did not participate in the National Prostate Cancer Audit or the National Nutrition and hydration Oesophago-Gastric Cancer Audit 2014. • We observed risks assessments in place for nutritional • Ealing Hospital submitted data related to 94 hip and 155 needs and these had been reviewed as part of the knee joint surgical procedures to the National Joint progress reports. Registry (NJR) so far in 2015. We noted they had also

56 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

performed two shoulder and one ankle replacement. This included, for example, no details about the Consent by patients to be included in the NJR was 100% availability of a reserved operating theatre for year to date. Outcomes were as expected for knee emergency surgical patients 24/7; lack of information to procedures undertaken between April1 2014 and March confirm a minimum four tier EGS rota at all time; details 31 2015. There was no outcome data for the hip about the availability of a critical care outreach team 24/ replacements available on the NJR. 7, and if there was a policy for anaesthetic seniority • The National Hip Fracture Audit for 2013/14 indicated according to risk. There was no information about the that 140 cases were submitted from Ealing Hospital in pathways for enhanced recovery of patients and no 2014. Of these five of the indicators performed worse details to indicate the responsibilities of the surgeon to than the England average. This included only 12.3% of formally hand over patients in person. patients being admitted to orthopaedic care within four • The National Emergency Laparotomy Audit for 2015 hours, against the England average of 48.3%. Surgery indicated four areas where the proportion of patients for was performed the day of admission or the following which each process of care was not met. This included day in 65.7% of cases, compared to 73.8% England the reporting of CT before surgery, pre-operative review average. Falls assessment had been completed in 86.5% by consultant surgeon and anaesthetist, presence of of cases, with an England average of 96.8%. Areas where consultants in theatre, and assessment of patient over Ealing Hospital performed better were with respect to the age of 75 years by an orthogeriatrician. patients having a bone health medication assessment, • Between January and December 2014 the average which was slightly above the England average at 97.6%. length of stay at Ealing Hospital for elective surgical The number of patients who developed a pressure ulcer patients was slightly above the England average at 3.6 was less than the England average at 2.4%. days, compared to 3.1. Patients having general surgery • Information related to patient hip fractures was and urology generally stayed for fewer days, 2.8 and 1.9 submitted to the National Hip Fracture Database annual respectively compared with the England average of 3.1 report 2015, (NHFD). We reviewed the annual report and and 2.1 respectively. However, patients who had elective noted 10.5 % of patients were reported to have been trauma and orthopaedic procedures stayed on average admitted to an orthopaedic ward within four hours. The 5.1 days, compared to the England average of 3.1 days. London average was 29% and overall average 46.1%. • Patients having non-elective surgery stayed on average The percentage of patients mobilised the day after slightly above the England comparator, at 5.4 days. The surgery was 34.4%%, compared with a London average main areas where length of stay was higher was trauma of 69.4% and overall average of 73.3%. The location and orthopaedics, at 8.9 days, compared to England performed better (above 90%) with regard to mental average of 8.5 days and urology, 3.6 day stay compared test assessments, preoperative medical assessment, a to England average of 3.3 days. For patient having falls assessment and bone health assessment. non-elective general surgery the length of stay was 3.6 • Patient Reported Outcome Measures (PROMS), were days, which was less than the 4.2 day England average. responses from a number of patients who were asked • Relative readmission rates provided to us did not whether things had ‘improved’, ‘worsened’ or ‘stayed the necessarily reflect accurate information since the same’ in respect to four surgical procedures, (groin merger. However, we noted from the information hernia, hip replacement, knee replacement and varicose available for elective surgery at Ealing Hospital trauma veins). The majority of indicators for Ealing Hospital and orthopaedics was the one area which exceeded the respondents suggested an improving picture when England average, with a 75% chance of readmission. For compared to the England average. non-elective surgery trauma and orthopaedics • Ealing Hospital was part of the North West London readmission rates were above the England average, and Trauma Network and had a shared aim of improving urology was also slightly above - at 58% and 9% patient care and their outcomes. respectively. • The trust’s self-reported National Emergency Laparotomy Audit for 2014 indicated that the provision of facilities required to perform emergency laparotomy was unavailable for 10 of the 28 measures reported on.

57 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Competent staff also attended the MDT meeting. We heard information, which demonstrated discussion of patient progress and • We reviewed a detailed training competency record for decisions around discharge needs. Staff were observed theatre staff, which included information with respect to working together to assess and plan on-going care and each staff member, what they had completed and when. treatment in a timely way when people were due to be • Staff told us they had the opportunity to identify and referred for other services or to be discharged. The discuss their training and development needs during meeting was quick and efficient and information from their performance review. We were told by staff they had the meeting was communicated to staff on the ward been able to undertake appropriate training to meet and at subsequent shift changeover. their learning needs. This included attending external • Nurses told us that for patients who were described as forums. For example a member of staff was funded to ‘long stayers’ there was a separate MDT meeting on attend a forthcoming conference related to day surgery. ward 7 North, which facilitated discussion of progress • Band five and six nurse who spoke with us in a focus and rehabilitation needs and included family members group reported there was good support for professional too. The MDT meeting held on a Friday on ward 7 North development, with trust provision through the was led by the care of the elderly consultant. education learning and development department. Staff • Patient discharge arrangements were aimed to take reported they had been encouraged and given place at a reasonable time of day. However staff on opportunities to develop themselves. For example, a Brunel Ward reported day case patients were band six nurse had recently completed the tissue discharged as late as 11pm. This was said to be for a viability course and a leadership and management range of reasons but mainly because the individuals course. were later back from theatre and had not sufficiently • The arrangements for supporting and managing staff recovered. We asked if there was any formal monitoring included one-to-one meetings, appraisals, coaching and of the numbers of late discharges and were told there mentoring. A newer member of theatre staff explained was not. Furthermore, we found the surgical care how they started their role with no prior experience and performance dashboard only collected data for patient how they had been supported by a nominated line discharges prior to 11am. manager as well as having opportunities to work with • Where patients required on-going care such as the various team leaders. They had completed interventions of a community nurse, referrals were competencies and had a six month review of their made prior to discharge. progress. • Most patients who spoke with us were aware of the • Staff had access to a practice development lead in arrangements for their discharge, including when that theatres. was expected to be and if they needed to have any • Appraisal rates were reported on the workforce and outpatient appointment or medicines. safer staffing performance indicators. For ward 7 North we saw a rate of 97% had been achieved in the year to Seven-day services date. In theatres the appraisal rate was 80% and on • There was provision of emergency theatres at all times, Brunel ward it was 97%. including out of hours. Surgical patients were seen daily • Information provided to us indicated there were 112 by a member of the surgical team for the speciality or by surgical staff in the surgical directorate, although these the on-call person. numbers were not site specific. Of these we noted there • Nurses reported having a limited service provided by had been 11 staff who required revalidation up to this radiology and for patient scans at weekends. They point in time and these had been completed. reported having access to pathology and pharmacy Multidisciplinary working services on Saturday and Sunday mornings. On-call service was provided for pharmacy outside of these • We attended the multidisciplinary team (MDT) on ward 7 hours and there was access to backup medicines. South, which on weekdays, Monday to Thursday was • There was a weekend physiotherapy rota for respiratory attended by occupational and physiotherapists, the patients and a voluntary seven day occupational discharge co-ordinator and nurses. On a Friday doctors therapy service across all specialities within the

58 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

hospital. In addition, an emergency out of hours on-call base, we found whilst it was indicated as a mandatory service for patients with respiratory complications was subject, there were no training results available. Further available out of hours 365 days of the year operating investigation found the course stated it was not from 16.30 to 8.30 am. ‘enrollable’ at the time. • We were provided with information with respect to • Staff were aware of the differing consent forms and surgical arrangements for out of hours (OOH) in the ENT where an individual lacked capacity, consent form four service. A service level agreement was said to be in was used. Best interest decisions were said to be made, place for out of hours ENT cover provided by another where possible involving the relevant family, power of hospital. The trust was said to be in negotiation with attorney or social worker. The consultant or registrar Ealing to take on full 24/7 cover at Ealing including signed the consent form when such decisions were on-call, surgery, and ward rounds. There was no urology reached. week-end and OOH cover on site. However, the ward • We found,in our checks of patient records, evidence of round was done by a senior SpR over the week-end. consent forms for a range of surgical procedures. In addition we noted a patient had signed a consent form Access to information to indicate the sharing of information with the National • We observed information needed to deliver effective Joint Register. Patients who were asked about consent care and treatment was available to ward and theatre reported having information provided to them so that staff. This included details of patient admissions, theatre they could make informed decisions. schedules, patient records, risk assessments and • We saw evidence of MCA assessment documented. guidance. • An audit of compliance with expected standards around • Information to support the delivery of services was consent was undertaken in July 2015. The sample of accessible on the trust intranet and also in paper copies consent forms reviewed included 37 relating to patients in most areas. on surgical wards at Ealing Hospital. Of these 70.3% had • We noted in minutes of clinical governance meetings been signed by the surgeon performing the theatre safety bulletins were discussed, along with operation but 24.3% had not been signed. A further patient safety alerts. 2.7% were illegible and operation notes were not • Referral information for community services, discharge, available in the remaining. Job title was stated in all transfer and transition was shared appropriately and in consent forms reviewed. The benefits of having the a timely way. surgery had been included in 97.2% and risks had been • An electronic discharge summary was completed for recorded in all forms reviewed. Responses from patients each patient. Patient discharge information was about consent presented favourable feedback in most communicated to GPs, with details of the surgery or of the questions asked. The lowest responses related to treatment the patient had received. Care summaries 25% of patients not having information about the type were provided on discharge to ensure continuity of care of anaesthetic they were to receive. An action plan had within the community. been developed from the findings and this included for example the provision of formal consent training. Consent, Mental Capacity Act and Deprivation of • We found from our checks of patient records and it was Liberty Safeguards confirmed by patients we spoke with there had been • A matron confirmed Mental Capacity Act (MCA) training discussion about potential risks. One patient told us as being an “essential” subject for staff to attend and the that in addition to having information about what content included consent and Deprivation of Liberty would be done if there was a problem; they were also Safeguards (DoLS). However, other staff were not sure if told what they were not consenting to. they had undertaken this training, but there was • Mental capacity to consent to care or treatment was awareness within the nursing staff of the importance of assessed during pre-admission or during their medical completing relevant documentation with respect to and nursing assessment, if admitted as an emergency. DoLS. We tried to identify the uptake for MCA and DoLS The outcome of such an assessment was documented training and when we looked at the electronic data in the individuals care record.

59 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

needed to check on patients more frequently and whilst Are surgery services caring? responses to call bells had been better that day, it was less so the previous day. This patient informed us that Good ––– the patient opposite them did not speak English as their first language and staff took a long time to respond to Patients reported positively with regard to the quality and their request for assistance. We were told by this patient standards of care they received from doctors and nurses. they would not recommend the hospital based on their Staff respected the individuality and needs of patients and experience. treated them with kindness, courteously and with respect. • We observed nursing staff to be responsive to call bells Patients told us their privacy and dignity was respected and whilst we were on the ward. they were involved in decisions about their treatment and • A patient who had previously experienced the services care. of the hospital reflected on their time on ward 7 South. They told us they had a good experience thus far, Patients reported their relatives and those closest to them everyone had been very friendly and “the doctors and were involved and kept informed as much as they wished nurses were very good.” Staff had been respectful and them to be. attentive towards them. There was access to information and support where • Two patients and the relative of one spoke with us on patients required additional emotional and psychological Brunel Ward and were very complimentary about their care. experience since arrival on the ward. One patient told us their expectations had been low but they had been Compassionate care “surprised by the level of kindness.” We were told by • From our observation of staff interactions and a review another patient it had been excellent, as their relative of information within patient records we noted that had been able to accompany them to theatre to assist in nursing and medical staff understood and respected communicating. people’s personal, cultural, social and religious needs. • One patient reported having had to wait for pain relief Relevant information was taken into account in and wound dressings because nurses were busy on addressing personal needs, such as diet and ward 7 South. They added that the delay was explained interpretation needs on wards. by nurses. Another patient on ward 7 North wanted to • Staff reported to us that they would raise concerns express how different their experience had been prior to about disrespectful, discriminatory or abusive admission, with three visits to the emergency behaviour or attitudes. department (ED) before they were finally admitted. They • We observed ward nursing staff, medical personnel and told us absence of notes from earlier attendance at the allied health professional ensuring people’s privacy and ED had contributed to staff not being aware of the dignity was respected as they went about their duties. severity of their condition. However, they told us their This included addressing people in a respectful manner care had been very good since admission to the ward. and by their preferred name; ensuring curtains were • We followed one patient from the ward through to the closed around bed areas and responding promptly to operating theatre and observed that staff interacted in a requests for assistance. Staff made every effort to polite and caring manner towards the patient. All respect patient confidentiality during ward rounds, procedures were explained fully to the patient before handover at shift changes and in their handling of carrying them out. sensitive information, including patient records. • Staff encouraged patients to be as independent as • We spoke with nine patients across the three ward possible and reflected their level of independence in the areas, all of whom commented favourably on their nursing documentation. For example, if a person could experiences of using the surgical services. For example mobilise freely or attend to their own hygiene needs. We the responsiveness of staff, of feeling safe and cared for. observed that patients were able to get out of bed and A patient on ward 7 South told us the nurses were nice sit in a chair or move about the ward areas, subject to and friendly, polite and kind. They did add that they

60 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

feeling well enough. We observed staff supporting assessed and addressed, including nutrition, hydration, patients with their mobilisation and being both pain relief, personal hygiene and anxiety. We saw supportive and encouraging in their approach towards progress notes written by nursing and members of the them. multidisciplinary team to reflect changes in needs. • Friends and Family Test (FFT) results for the period from • Staff understood the impact that a person’s care, March 2014 to February 2015 indicated an average treatment or condition had on their wellbeing and on response rate on ward 7 North of 27% and ward 7 South those close to them, both emotionally and socially. of 25%. There were at least two months on both wards Regular checks of patient wellbeing were taken in the where there had been no patient feedback via the form of comfort rounds. Family and carers were Friends and Family system. We saw results of FFT on encouraged to visit and be involved where possible in display and noted for example 89% of respondents on supporting their relative. ward 7 North would recommend the hospital year to • There was access to expertise and additional advice and date. support from specialist nurses, learning disability and dementia lead nurses. Understanding and involvement of patients and those close to them Are surgery services responsive? • A patient who spoke with us on ward 7 South reported a lack of information provision, both in the emergency Requires improvement ––– department and since their arrival on the ward. At the time of our discussion they said they did not know what was happening. Another patient on this ward told us Referral to treatment times were not being met in a they had been kept informed and their next of kin had number of surgical specialties. Adjusted referral to been involved in discussions. treatment within 18 weeks was worse than the England • Staff recognised when patients needed additional average between the period of September 2014 and April support to help them understand and be involved in 2015 for five surgical specialties. The referral to treatment their care and treatment. For example, staff recognised for incomplete pathways in October 2015 was 93.2% which and responded to the individual needs of a patient with was above the 92% standard. a hearing impairment and made sure they took time to Theatres were not always effectively utilised and operating communicate clearly but also that their relative was sessions started and finished later than planned, which able to be present at times when essential information impacted on patient discharges. needed to be communicated. • We saw evidence and heard from patients that they had The hospital operational management team had oversight opportunities to discuss their health needs, concerns of the status of the hospital at any given time and bed and preferences to inform their individualised care. availability was managed well. However, the generic documentation used by nurses did The individual care needs of patients were fully considered not facilitate the inclusion of specific details related to and acted on by staff. Arrangements were provided to choices and preferences. support people with disabilities and cognitive • Most patients told us they had been given information impairments, such as dementia, although there had been to assist them to understand relevant treatment little focus on developing the surgical services to improve options, including benefits, risks and potential the environment for such patients receiving surgery. consequences. This included formal consent prior to Translation services were available and staff had access to surgery and informal agreement prior to interventions, information and expertise to facilitate responsive such as taking blood. communications. Emotional support • A review of patient care records demonstrated patients had their physical and psychological needs regularly

61 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

The complaints process was understood by staff and • Cancellation data provided to us indicated that, out of patients had access to information to support them in 277 listed operations in September 2015, 233 took place. raising concerns. Where complaints were raised, these were There had been five cancellations for hospital reasons investigated and responded to. Any improvements (1.8%), 39 for patient reasons, (14.1%), including nine identified were communicated to staff. patients who did not attend. • Between January 2014 and March 2015 there had not Service planning and delivery to meet the needs of been any patients who did not have their treatment local people within 28 days of a cancelled procedure at Ealing • Services had recently been reviewed and changed to Hospital. address the emerging strategy of the trust. Gynaecology • Endoscopy staff reported there were insufficient surgery had moved to Ealing Hospital and other services endoscope stacks, with no back up for times of failure. had moved to separate locations within the trust. In addition during the week, if a stack and flexiscope • There was access to pre-assessment clinics, which was required in theatres, a scheduled list in endoscopy facilitated preparation and planning for surgery based would be delayed and or cancelled. on patient need and any identified risks. • We found theatre times did not always run to expected times and we noted that where delays were identified Access and flow staff reported these on the Datix system. • Access to surgical services was via GP referral subject to • Multidisciplinary meetings included discussion of consultation review or via the emergency department patient discharge arrangements. The discharge (ED). co-ordinators engaged with other staff at the ‘morning • Information related to referral to treatment (RTT) within and lunch time bed capacity meetings so that 18 weeks was supplied for the trust and was not information could be shared. We noted the performance location specific. This indicated five surgical specialities scorecard for the surgical division indicated 9.8% of not meeting the targets, including; general surgery patient discharges happened before 11am in July 2015, (69.1%) RTT, trauma and orthopaedics, (83.4%), urology, with a year to date figure of 12.5%. (83.2%), ENT (82.8%) and oral surgery, (74%). • Theatre staff told us they were made aware of the • There was provision for pre-admission assessment by location of surgical “outliers” on other wards and the designated nurses. The pre-assessment service was detail of ward location was made clear on the theatre described as “very good” by one patient and that it was list. very thorough. Meeting people’s individual needs • With the exception of two patients we were not made aware of any problems in having access to initial • Surgical services were accessible to all regardless of assessment, diagnosis or urgent treatment. The service disabilities. Arrangements had been made to make prioritised care and treatment for people with the most facilities accessible with appropriate aids. Wards urgent needs and there was access to emergency provided single sex accommodation and access to theatre. separate toilet and bathing facilities. • There was an appointments system for outpatients and • The endoscopy department did not have the ability to investigative procedures, of which one patient reported segregate female and male patients in the area used for some degree of confusion and unnecessary cancellation pre and post procedure care. To mitigate this staff were due to poor communication. The latter had resulted in having to ensure that admissions were managed so that them having to contact the department directly to males came on one day and females on another. reorganise. • Multidisciplinary meetings took place specifically • Theatre utilisation was not always effectively achieved. for long stay patients, during which progress was Data was provided for Ealing Hospital, which indicated discussed along with rehabilitation needs. average utilisation of 70.7% across the period July to Arrangements for on-going care took account of September 2015. individual needs of people being discharged with complex health and social care needs.

62 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

• Ward staff confirmed that they were able to make links merged across sites and was challenging. They with interpreters via telephone or if necessary face to indicated that this was because there were different face. However, staff working in endoscopy reported approaches, and tracking was difficult, making it hard to feeling frustrated as they had to arrange lists around the get a grip across all three sites. They told us some availability of interpreters. This was despite many staff aspects were being worked on and a common database being multi-lingual but not being permitted to interpret was in development. in line with the trust policy. • Information was displayed in surgical areas with respect • Nursing staff confirmed there was access to information to raising a concern or complaint. and expertise related to the provision of care to support • We saw there was a formal process in place for people with a learning disability. We saw relevant recording complaints, the location and specialty, date information displayed on the notice board on ward 7 received and outcome. This included if the matter was South to guide staff. A detailed resource file was closed or not. available on Brunel Ward, which contained a range of • We reviewed examples of final letters written to communication tools and other guidance. complainants, in which the trust acknowledged the • We observed staff supporting individuals where they matters raised and investigated and responded needed help with eating or drinking because of their accordingly. The process reflected an open and frailties. A purple flower symbol was used to indicate transparent process. where staff were required to support people to eat and • We saw that clinical governance meetings were used as drink. an opportunity to discuss complaints, feedback from • We noted there was a trust wide dementia strategy, these and any required action. For example, the minutes which outlined the aims and objectives for improving of the urology clinical governance meeting held on 9 inpatient and community patient care with respect to July 2015 included actions to be taken to address the dementia services. However, we found that there had provision of information related to possible been little focus on developing the surgical services to post-surgical complications. take into account the needs of people who were living with dementia. With the exception of a side room on Are surgery services well-led? ward 7 North, we did not see any evidence that attention had been given to the environment to make it Requires improvement ––– dementia friendly. We saw a ‘forget-me-not’ sign in use on ward 7 North but not elsewhere. In our discussion with staff they confirmed that apart from providing one The surgical risk registers did not always identify the to one support if necessary, and having links to the relevant hospital location where the risk dementia lead nurse, there had not been any measures presented. Timelines had not been assigned for resolution taken to improve this area. of risks in all cases. • Nursing staff told us patients could be referred to the Staff reported positively on their immediate line managers, mental health nurse for psychiatric support. their approachability and support and said they • We noted there was a range of literature available for were valued and respected, but reported a disconnect patients and visitors to access on wards. This included between the locations and a lack of visibility of senior for example, safeguarding information, slips, trips and personnel. falls advice, information on neck of femur fractures. • We observed that there was a range of cultural and The majority of staff did not have a full awareness of the medical related diets available to patients to choose broader vision and strategic aims of the surgical directorate from. For example; low fat, Kosher, Halal, Diabetic, or the trust itself. This reflected the lack of information they Vegan and African or Caribbean main courses. perceived in relation to future services at Ealing Hospital. Learning from complaints and concerns Senior leaders understood their roles and responsibilities and were aware of the impact the recent changes following • Senior nurses who spoke with us in a focus group the merger had on staff. reported that the complaints department had not been

63 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Effective governance arrangements were in place to Governance, risk management and quality monitor, evaluate and report back to staff and upwards to measurement the Trust Board. • The surgical directorate was overseen by a divisional The surgical directorates identified actual and potential clinical director, general manager and head of nursing. risks at a service and patient level and had in place There were two divisional governance co-ordinators and mechanisms to manage such risks and monitor progress. one designated service improvement lead. Staff holding these roles were clear about their responsibilities and Patients and staff were encouraged to contribute to the understood what they were accountable for. running of the service, by feeding back on their experiences. • The performance management data collected for surgical services included a range of areas, such as Vision and strategy for this service patient safety and the patient’s experience. Performance • There was an absence of overall awareness of a vision indicators were reported monthly and were reviewed as for surgery. There had been workshops around a part of the governance processes. divisional strategy but there was not a vision and • Senior nurses who spoke with us in a focus group strategy document in place at the time of our meeting reported since the appointment of the new inspection. Information about it was piecemeal. CEO changes in risk management and governance • There was a mixed response from clinical staff, including structures had given them more assurances. For those in more senior positions as to their understanding example, there was a more structured reporting via of the trusts overall vision and aims. We were told by a dashboards of key performance indicators (KPIs). member of nursing staff the trust vision was about high • Senior nurses told us they did not necessarily attend the quality patient care, providing a good service, a good monthly clinical governance meeting but they attended experience and about looking after staff. A junior doctor sister’s forums, where they received information from who spoke with us was not aware of the trust values and matrons. aims. • Management of the risk register appeared disjointed. A • A member of theatre staff told us the aims and matron informed us the risk register was reviewed at the objectives had not been shared widely. However, there clinical governance meeting, which mainly took place was awareness in nursing and theatre staff of the move on other hospital locations. Because of this they had to of some surgical services. It was evident from staff they prioritise if they went to the meetings or not. They were had concerns about the future of the location and they not aware what risks were on the register relating to commented on the lack of detailed information about Ealing and hence the risk register did not necessarily the direction of travel in relation to services and the contain all the risks at Ealing. hospital itself. • We reviewed the surgical risk register and found this • We spoke with the divisional leads for the surgical identified risk by specialty, type and attached a risk directorate about the service strategy. We were rating. A responsible lead was assigned and the risk informed there had been several workshops around the management plan had been summarised and progress development of a strategy, which had included noted. However, it was not always clear which site the post-merger meetings with surgeons and anaesthetists risks related to and timelines had not always been to discuss where services should be. Most of the aims assigned to risks for resolution were said to have been achieved, such as moving services within the separate locations. For example, the Leadership of service majority of gynaecology services had moved to Ealing • During our discussion with a number of consultants they Hospital in order to strengthen their services. told us the board level management were not visible • We reviewed several copies of minutes for the theatre and unsupportive, with the exception of the Medical users committee meetings. These contained a regular Director. They added decisions were made and policies agenda item related to the surgical strategy and enforced without the backing of the teams, for example, progress on this.

64 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

they had been told to conduct bi-weekly M&M meetings, lots of issues and problems on site. This made it difficult but did not have the time to facilitate them. Further, at times and an example was cited where there had they did not have protected handover time, despite been a bomb scare six weeks earlier and there were no presenting evidence showing they should. other senior managers on site. • We observed staff working well together in all areas • The chief executive and lead nurse were said to have visited. There was enthusiasm and willingness to been visible on the ward and in theatres. Staff told us provide high standards of care. These observations they also received weekly reports, which had lots of supported feedback we had received from senior detail therein. nurses, who reported an ‘all hands on deck’ approach Culture within the service when needed. They told us there was a good consultant and matron presence on site, so issues were usually • Nursing staff told us they were respected and valued by resolved. their colleagues, were able to share ideas and • Staff working on wards and in theatres reported their suggestions and they were listened to. One nurse told us immediate leaders as being knowledgeable and the manager had called them to give a letter of supportive. When band six and band seven nurses took commendation from a patient. charge they were reported by one nurse to be quite well • The culture was described by a matron as being friendly, led. like a family, with mutual help to one another. They did • Matrons were described as being polite and caring say there was a degree of low morale as there were towards patients and that they were very approachable. worries about the future of surgery provision at the There was an awareness and understanding of the location. problems experienced by staff on the ‘shop floor’. A • We were told by nursing staff the culture enabled them matron reported to us considerable changes in to speak up and they had confidence things would be management since the merger, both positive and dealt with and that confidentiality was also respected. A negative. member of nursing staff reported a fair approach to • However, most managers were based at Northwick Park training and progression, which was anti-discriminatory. location. Matrons reported feeling supported and • Theatre staff reported being able to work well with having regular communications, as well as being able to consultants and that they were approachable and attend meetings. The latter was said to be difficult due respectful towards them when they asked questions. to travel but there were video links to facilitate • Safety and wellbeing of staff was reported by staff to be engagement. considered by managers. There was a focus on safe • Band five and six nurses who spoke with us at a focus staffing levels and awareness of the impact of working group reported a sense of loss of senior nurse over and above expected hours. leadership at a time when they needed support and that • Sickness absence was monitored and there were leaders were often at Northwick Park Hospital (NPH). policies in place to address capability. They also reported a lack of visible management in the Public engagement hospital since merger. • Senior nurses who spoke with us in a focus group • We asked nursing staff if there was any public indicated that it was difficult to sustain a presence engagement taking place to gather their views and help across three sites, as well as community. We were told it shape the services. There was no awareness of such was difficult to manage staff expectation of their engagement. visibility across sites. • We noted feedback from patients and their families was • Site managers and practitioners had video conferencing gathered through the Friends and Family Test. In and we were able to observe this in action within a bed addition the wards had ‘you said, we did’ boards and meeting and capacity review. On the Ealing Hospital site information was recorded on these. For example, noisy we were told there was one site manager to deal with at night was mentioned and in particular the noise from bin lids closing. The response was that new soft closure bins had been ordered.

65 Ealing Hospital Quality Report 21/06/2016 Sur g er y

Surgery

Staff engagement Innovation, improvement and sustainability • Staff in theatres reported poor staff survey engagement • We asked staff to tell us about any innovations or and of feeling they may be targeted if they wrote aspects of their work which should be celebrated. Staff anything negative. We saw an action plan had been could not describe any examples of anything developed from the results of the most recent staff extraordinary happening or any particular projects or survey. The actions related to mandatory training, activities. They did tell us in theatres how they appraisals and bullying. celebrated the fact they were heading in the right • The staff survey results for 20 March 2015 were reviewed direction, that morale was much better than it had been by us. We noted 69% of respondents on ward 7 South two years ago. reported to agree they perceived themselves to be part • The service had received an excellence award for quality of a strong team with a good team spirit and 15% improvement in reducing time to surgery for patients strongly agreed with this question. 38% and 15% with fractured neck of femur. The outcomes showed a respectively either agreed or strongly agreed with the reduction in mortality from 8.5% to 4% over a year and question: My opinion matters in how the ward/ time to surgery from 48% to 93% within 36 hours of department is run. However, 15% strongly disagreed admission. with the latter question. There were no results reported • Nursing staff had been encouraged and supported to for ward 7 North or Brunel. continuously learn through such courses as mentorship • Staff did not feel actively engaged in the planning and and leadership programmes. We were not given any delivery of services and in shaping the culture or the examples of how such learning had contributed to future of services. improvement or innovation. Despite this staff were very • Staff understood the value of raising concerns and said aware of the need to focus on the delivery of quality these were generally acknowledged and addressed. care and recognised how information provided from performance results contributed to enhancing patient care outcomes.

66 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

Safe Good –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Good –––

Information about the service Summary of findings Critical care at Ealing Hospital (EH) is delivered within a Overall the critical care at EH was good. Patients were nine-bedded unit separated into individual patient rooms cared for by a safe number of competent staff who used which is located on the first floor of the hospital. The unit evidence-based practice to achieve good outcomes. could accommodate a maximum of nine level three Staff had good access to patient information and patients at any time, although a combination of level two current best practice guidelines as well as up to date and level three patients was usual. Level three patients research articles. Patient safety thermometer results require advanced respiratory support alone or basic were good and there was a proactive incident reporting respiratory support along with support of at least two culture. We saw evidence that incidents were organ systems. Level two patients require detailed investigated appropriately, with learning points observations or interventions and require higher levels of disseminated to unit staff,. hHowever, there was limited care due to a single failing organ system or postoperative shared learning relating to incidents. The vision for the care. There were 225 admissions to the critical care unit service focused on an improvement in quality and between January and July 2015. safety through investment in staff training and Most patients (76%) are admitted to critical care after development. We saw some evidence of innovation becoming unwell on the hospital wards or via the such as the development of the high flow oxygen emergency department due to complex medical needs. service. Some patients (24%) are admitted following elective or The critical care service was caring and patient privacy emergency surgery. A critical care outreach team is and dignity was maintained at all times. Staff knowledge available to assess deteriorating patients on the wards and and implementation of safeguarding was good and we to follow up patients who have been stepped down from saw evidence that regular patient risk assessments took critical care place. Patients’ pain was frequently assessed and well We visited the critical care unit over the course of two managed by staff who ensured patient comfort at all announced inspection days. During our inspection we times. spoke with 22 members of staff including doctors, nurses, Multidisciplinary working was embedded on the unit, allied health professionals and ancillary staff. We also particularly during the weekly meeting.However there spoke with the critical care leadership team, three patients were insufficient number of pharmacy and dietetic staff and four relatives. We checked seven patient records and to meet best practice recommendations. Senior and many pieces of equipment. junior staff’s knowledge of consent and Deprivation of Liberty Safeguards was variable.

67 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

There was a capacity shortfall on the unit and we saw Are critical care services safe? difficulties with patient flow through critical care. This was not on the department or trust risk register and Good ––– there was no strategy in place for addressing the capacity shortfall. There were higher occurrences of unit-acquired methicillin-resistant staphylococcus Safety within the critical care unit was good and people aureusis and blood infections than on other similar were protected from avoidable harm and abuse. There units. were thorough patient risk assessments completed at suitable intervals and staff responded appropriately to Staff perceived that there was a poor relationship with changes in risks. Patient safety thermometer results were trust senior management. In their opinion the critical good. Staff demonstrated appropriate knowledge and care service was not valued within the organisation. understanding of safeguarding principles, and we observed Senior staff expressed concerns at the lack of embedded systems to keep people safe from abuse. understanding relating to critical care and hesitation at raising problems with trust management due to Staff understood what types of situations needed to be potential repercussions. reported as incidents and were proactive in doing this. Investigations completed as a result of these reports were suitably thorough and involved all relevant staff members. Lessons were learned and communicated across the critical care unit to prevent the same incident occurring again. Staff understood and adhered to duty of candour principles. Patients were cared for on a clean unit where staff followed infection prevention and control principles, including the correct use of personal protective equipment, however there were more cases of methicillin-resistant staphylococcus aureusis and unit-acquired blood infections than on other similar units. Medicines were prescribed, stored and administered correctly, however pharmacy provision on the unit was not in line with recommended levels. Patients were cared for by safe numbers of nursing staff; however staff feedback and our observations suggested an additional supernumerary member of staff to assist with patient care tasks, and to allow staff adequate breaks, would be beneficial due to the layout of the unit limiting staff working together. There was suitable provision of medical staff to care for patients on the unit but all the doctors left the ward to attend the weekly multidisciplinary meeting. This left the unit without a doctor immediately available, which does not follow recommended practice. Uptake of certain aspects of mandatory training was poor. Incidents • Incidents were reported on electronic forms which were accessed by all trust staff on any trust computer. We saw evidence of staff reporting incidents during our

68 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

inspection. There were no serious incidents or never • We saw evidence of letters to patients and their families events relating to the critical care unit between April and demonstrating adherence to duty of candour principles September 2015. Serious incidents known as ‘Never when incidents had occurred. These letters contained Events’ are largely preventable patient safety incidents apologies and provided thorough explanations of the which should not occur if the available preventative incidents and learning points which had been raised as measures had been implemented. a result of this. • Staff on the critical care unit were aware of the incident Safety Thermometer reporting process and were able to give a range of incident examples which would trigger an incident • The NHS Safety Thermometer is a national tool used for report, including near-miss scenarios. Staff told us measuring, monitoring and analysing common causes incidents were “almost always reported on the same of harm to patients, such as new pressure ulcers, day”. catheter and urinary tract infections (CUTI and UTIs), • We saw evidence of root cause analysis (RCA) taking falls with harm to patients over 70 and Venous place when incidents had occurred and these RCAs Thromboembolism (VTE) incidence. Safety demonstrated thorough investigations which involved thermometer and safe staffing details were displayed on all relevant members of staff. Staff had access to a noticeboard in the critical care unit. Safety completed RCAs relating to incidents which had thermometer data detailed below refers to the period occurred on the unit as these were stored in a folder on October 2015 to September 2015. the ward. Learning points from incidents were passed • There were two unit acquired pressure ulcers reported on to ward staff during staff meetings, handovers or by on the critical care unit. During our inspection, we saw email. patients’ risk of developing a pressure ulcer wasere • Staff told us they usually received feedback for incidents assessed using the Waterlow pressure ulcer prevention they had reported although there were some occasions score. A staff nurse was identified as the tissue viability they had to request information regarding the outcome. link nurse who worked closely with the hospital tissue Staff confirmed general incident feedback occurred viability team to ensure best practice was followed in during handovers and staff meetings and they said this critical care. was an effective way to communicate the learning • Catheter care bundles were used throughout critical points raised. care and there had been no instances of CUTIs during • Regular multidisciplinary clinical governance meetings the data period specified. were held; they discussed themes of incidents which • There were no falls with harm to patients in intensive had occurred on the unit, action points identified and care during the reporting period. We saw evidence of reviewed actions from previous incidents. completed falls risk assessments and timely referrals to • They held morbidity and mortality meetings which physiotherapists were made when concerns arose. reviewed the clinical management of any patients who • VTE assessments were recorded on the daily care chart had died on the unit and analysed whether the care and completed each day. There were no new VTEs received by the patient was correct, appropriate and within critical care during the reporting period. Hospital suitably optimised. These governance processes were in audit data demonstrated 100% of patients were line with recommendations from the ‘Faculty of assessed for VTE risk at appropriate intervals during Intensive Care Medicine Core Standards for Intensive their admission to critical care which was in line with Care Units’. National Institute for Health and Care Excellence (NICE) • Senior critical care staff demonstrated a thorough quality standards. understanding of principles relating to duty of candour requirements and told us the responsibility for this Mandatory training would lie with the lead consultant or lead nurse. Staff across all levels described the need to be open and honest about mistakes and to apologise when incidents occurred.

69 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• General mandatory training (such as fire safety) was • Waterproof mattress covers were intact and mattresses delivered as part of the generic trust induction process. were free from stains. We noted all fresh bed linen and Refresher courses and role specific mandatory training blankets were free from stains and holes. We observed needed to be booked separately and was the nursing staff disposing of used linen correctly into responsibility of each individual to organise. laundry bags; using separate red bags for linen used • Staff were able to complete their mandatory training with barrier nursed patients. during working hours, with time off the ward allocated • Due to the layout of the ward, all patients were nursed in order to complete this. Most mandatory training was in individual rooms even if they did not require barrier delivered via face to face learning but some modules, nursing. Where patients did require barrier nursing, we such as information governance, were completed on saw warning signs in place on the door to the patient’s e-learning systems. Staff told us there were not enough room to alert staff personal protective equipment (PPE) mandatory training sessions held so sessions were often such as gloves and aprons should be worn. fully booked and it could be difficult to tie in training • None of the patient rooms had a decontamination with days off the ward for training. lobby which was not in line with HBN0402 building note • Mandatory training rates were generally low with some recommendations for accommodating barrier nursed important topics such as infection control (72.88%), patients. Two patient rooms had negative pressure information governance (58.33%) and medicines capabilities which meant they could prevent airborne management (26.79%) particularly low. infective particles from spreading outside the patient • Senior staff told us the trust target uptake for each room. mandatory training topic was different and this • Alcohol gel was available at the entrance to the unit and sometimes led to confusion when assessing the there was a sign reminding staff and visitors to clean performance of the unit. They identified certain their hands when entering. mandatory training topics they wished to address as a • There were hand washing facilities within each room matter of urgency, for example pressure ulcer and a full complement of basic PPE such as aprons and prevention and management (39.29% completed). various size gloves available at the entrance to the room. Alcohol gel was also available at the entrance to Cleanliness, infection control and hygiene each room and at the patient bedside. • There was a member of housekeeping staff who • We observed staff members adhered to the ‘bare below provided dedicated support to the critical care unit the elbows’ policy and wore PPE appropriately to between 7am and 3pm on a daily basis. Further complete patient tasks. We noted correct removal and housekeeping support was provided between 3pm and disposal of PPE and adherence to hand hygiene 7pm. Outside of these times, housekeeping services protocols, including washing hands with soap and water were available via a bleep system. or use of alcohol gel. • Nursing staff were responsible for cleaning all medical • Data from the ‘Intensive Care National Audit and equipment which was in use such as ventilators, any Research Centre’ (©ICNARC) database demonstrated a equipment which had been used with a patient such as consistently higher occurrence of unit-acquired a commode or pat slide, and any spillage of bodily methicillin-resistant staphylococcus aureusis (MRSA) fluids. All other areas of the ward were the responsibility between January and June 2015 than on other similar of the ward housekeeper. units. • Housekeeping staff used colour coded cleaning • ICNARC data showed there was generally a lower equipment to limit the risk of cross contamination incidence of C. Difficile than on other similar units. between clinical areas, for example yellow cleaning Hospital audit data demonstrated there were no cases equipment was used in isolation or barrier nurses areas. of hospital acquired on critical care C. Difficile between • The critical care unit was clean throughout although we April and July 2015. noted a significant coating of dust on several bedside • Unit-acquired blood infections occurred consistently fans and some dust on high level surfaces, such as on more frequently on the critical care unit than on other the top of the bedside patient monitors. similar units between January and June 2015 according to ICNARC data. Senior critical care staff told us they had

70 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

implemented an improvement action plan which • There was a resuscitation trolley available within the included the allocation of a lead nurse in intravenous main ward area and also within the theatres recovery (IV) line care, reviews of the central venous catheter area. These trolleys were sealed with a plastic lock and (CVC) packs and review of aseptic non-touch technique we noted weekly checks were completed and training. According to staff, the trend of unit-acquired documented. There were no gaps in the checking blood infections was improving as a result of these documentation we observed. changes. Compliance with CVC care bundles was • Consumables within the unit were kept in storage reported as 96% between April and June 2015 according cupboards containing labelled shelving and drawers so to data from the North West London Critical Care staff could quickly locate the items they were looking Network. This was in line with the performance of other for. All consumables we inspected were seen to be in units in the local area. date. Stocking up the storage area was the responsibility of the health care assistants and staff told us there were Environment and equipment no issues relating to the availability of items. • Entry to the unit was obtained via a staff controlled • The trust sub-contracts to a specialist contractor for all video buzzer entry system which meant staff knew who its medical equipment maintenance and to manage wanted to come onto the unit before granting them safety testing and day to day functioning issues. Most entry. We saw staff checking a visitor’s identity against a equipment was replaced via a 5five year replacement list of authorised people to see a specific patient who programme and funds for replacing capital equipment had complex social issues and was only receiving had to be obtained via business case submission. certain visitors. Electrical equipment was labelled as having been • There were five patient rooms within the main ward portable appliance tested (PAT) and had a date for area which were usually used for level three patients review in place. and four additional rooms in the theatre recovery area • Staff received specific training on some items of medical which were mainly used for level two patients. Most equipment. For example we observed nursing staff patient rooms were not large enough to comply with receiving training on the new digital storage system for HBN0402 guidelines.. medicines. Additional training records demonstrated • Pendant patient monitoring equipment was present in other training on certain items such as the arterial blood each room which meant staff could access all sides of gas analyser. the bedside. Staff told us the monitors needed replacing Medicines soon due to "old age" and this was logged on the risk register for the unit. New monitors had been chosen and • There was a 0.5 whole time equivalent (WTE) critical staff told us the new system would allow remote patient care pharmacist dedicated to the unit between 9am and monitoring, such as if a patient was taken for a CT 12:30pm Monday to Friday, supported by a pharmacy scan.Staff on the unit would be able to monitor the technician for two hours per week. The Intensive Care patient’s vital signs remotely in addition to the staff Society states a 0.9WTE pharmacist would be required member escorting the patient. for the number of beds on the critical care unit and so • Clinical waste and general waste bins were available the current provision did not meet recommendations. within each patient room and also within the ward area. • The pharmacist was responsible for checking patient All bins were soft closing and none were seen to be prescriptions for interactions, allergies and correct overfull. prescribing. The pharmacist also ensured adequate • Needle sharps bins were located in each patient room stock and appropriate storage of medicines on the unit, as well as within the medicines preparation area. All • Medicines were prescribed on paper-based medicines sharps bins we checked were labelled correctly and administration charts which contained details of patient none were seen to be overfull. allergies, including the reaction caused by the medicine. • An arterial blood gas analyser was available on the ward Charts we reviewed were legiblye and details of the and staff told us this machine was calibrated at regular intervals. The machine was seen to be clean throughout our inspection.

71 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

medicines prescribed were correctly filled in, including • Oxygen canisters were available on the ward within each dose and route of medicine administration. patient bed space and within an oxygen storage area. All Prescriptions showed evidence of review by the ward oxygen we reviewed was seen to be in date and all pharmacist. canisters were correctly stored in appropriate racks. We • We noted antibiotics were prescribed in line with best noted an empty oxygen cylinder in a patient room which practice recommendations and trust guidance was had not been replaced. Staff rectified this issue available on the intranet. Additional assistance could be immediately when we informed them of our findings. sought from the British National Formulary or from Records microbiology support. • Medicines charts which were in use at the patients’ • Patient documentation was recorded on paper-based bedside had been fully completed, including signatures forms on the critical care unit. Daily care charts were when medicines were given or reasons for delay and used by nursing staff to record patient observations and omissions of medicines. activities, such as washes and repositioning. The daily • Medicines stored in critical care were kept in an care record also documented which lines the patient electronic storage unit which were accessed via a had in place and various assessments, such as the username and fingerprint log in. Staff had their own patient’s conscious level and VTE risk. Patient records individual log in details to access medicines and had we reviewed demonstrated full documentation of care received specific training for this equipment. Agency bundle compliance and were readily accessible to staff staff were allocated a log in for this which lasted for a but stored in a way which would limit access to patients' one week period. relatives and visitors. • Some medicines were stored within a lockable • Nursing notes were recorded on specific forms and kept medicines fridge. We noted temperature checks were in a special folder at the patient bedside. Nursing notes recorded on a daily basis and there were no gaps in contained holistic information about the patient’s day, these checks on the records we reviewed. such as whether any family members visited, as well as • We observed nursing staff administering oral and any significant medical occurrences. Entries were legible intra-venous medicines while following correct and most were were signed, with the staff member’s procedures, including checking the medicine with name printed below. another member of staff and the patient’s identity. • Entries from the critical care medical team and any • Controlled drugs (CDs) were stored in a separate visiting medical teams were documented in the lockable cupboard and required two nurses to be patient’s medical notes, which were also stored at the present for these medicines to be prepared and patient’s bedside. There were loose sheets of administered to patients. The keys to the CD cupboard documentation within the medical notes of some were held by the nurse in charge during each shift and patients on the unit which could be easily lost if the staff could access the keys by locating this member of notes were moved. Most entries by the medical team staff on the ward or by bleep. were legible and had been signed by the relevant • We observed nurses on the critical care unit professional. administering CDs following correct procedure, Safeguarding including two members of staff present to access the cupboard and double checking of the medicine and • A trust safeguarding policy was in place and accessible patient prior to administering the medicine. to all staff on any trust computer. Ward nursing and • The contents of the CD cupboard were checked on a medical staff knew how to access this policy and could daily basis by two members of staff; usually the nurse in identify who to contact if a safeguarding referral was charge and another registered nurse. The contents of needed. the cupboard were checked alongside the CD book and • Safeguarding adults level two training had been we noted accurate entries within the book, including completed by 84.75% and safeguarding children level two staff signatures for all medicines taken from the two training had been completed by 72.88% of critical cupboard. care staff.

72 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• We observed discussion of a safeguarding referral patient deterioration, as indicated by their observations. during the weekly multidisciplinary meeting. Clear Patients scoring five or above were referred to the reasons for the referral were identified and the action of critical care outreach team for review and consideration making the referral was designated to a member of staff of transition to critical care. who was asked to feedback to the team once this had • The critical care outreach team was available 24 hours been completed. Staff members involved in this per day, seven days per week. Between January and discussion were familiar with the processes and September 2015, there was an average of 113 referrals principles relating to safeguarding. made to the outreach team every month for patients scoring seven or more on the NEWS. This demonstrated Assessing and responding to patient risk an increase of 71% since 2013. Staff told us audit data • The Waterlow pressure ulcer prevention score was used showed there was a clear increase in calls to the to assess patients' risk of developing pressure ulcers outreach service when maximum capacity on the critical during their admission. Staff described how to calculate care unit was reached. this score and we saw evidence it was calculated at • The critical care outreach team were also responsible appropriate intervals. Staff told us special pressure for following up patients who had been discharged from relieving mattresses were used in critical care and critical care to the wards within the previous 48 hours. special gel seat pads could be ordered if needed. We • Data from the ICNARC database demonstrated there noted that pressure ulcer prevention and management were more in-hospital cardiopulmonary resuscitation training had been completed by only 39.29% of staff. (CPR) admissions to the critical care unit between • Falls risk assessments were completed for mobile January and June 2015 than in other similar units. patients or confused patients who may try to mobilise Nursing staffing independently. Staff told us physiotherapists would have early involvement with these patients and put in • Nursing staff worked in shifts from 8am to 8:30pm and place measures to reduce the risk of patient falls such as overnight from 8pm to 8:30am. Handovers were using socks with underfoot grips to limit the likelihood completed at 8am and 8pm each day and comprised of of slipping. a general overview of all patients on the unit from the • According to trust policy, the Confusion Assessment shift leader before nurses received specific bedside Method for the ITU (CAM-ITU) was used to assess handovers for their allocated patient/s. This ensured whether patients were delirious whilest on the unit. This patients were cared for by safe levels of staff even during practice was in line with current best practice guidance shift changeover times. from the Faculty of Intensive Care Medicine Core • The Faculty of Intensive Care Medicine Core Standards Standards for Intensive Care Units. We observed this for Intensive Care Units states that all ventilated patients assessment had been completed with appropriate (level three) are required to have a registered nurse to patients on ITU. patient ratio of a minimum of 1:1 to deliver direct care, • Risk of VTE was assessed during the admission clerking and for level two patients a ratio of 1:2. The critical care for new critical care patients and on a daily basis after unit used an acuity tool to assess the required staffing this. All patient charts we reviewed had completed VTE levels. Safe staffing data provided by the hospital assessments and hospital audit data consistently demonstrated staffing levels of registered nurses was showed 100% compliance. We saw mechanical and 98-103% of the planned levels between April and July pharmacological measures in place to reduce the risk of 2015. VTE. • There was a ward matron who was responsible for • Throughout the hospital, a National Early Warning Score overseeing the critical care unit as a whole and a band (NEWS) was calculated whenever the patient’s seven shift leader who managed the day to day running observations were taken which was in line with of the unit. Both of these staff members were guidance from the Royal College of Physicians. The supernumerary, as recommended by the Faculty of purpose of NEWS was to enable early identification of Intensive Care Medicine Core Standards for Intensive Care Units.

73 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• The remaining staff were allocated to patients and were • The Faculty of Intensive Care Medicine Core Standards a combination of band five and band six nurses. Senior for Intensive Care Units recommends no more than 20% staff told us they tried to ensure a good skill mix during agency staff usage per shift. Documentation we each shift so there was sufficient support in place for reviewed demonstrated use of agency staff within less experienced staff members. critical care was compliant with this standard. • At times it was necessary for patients to be cared for Medical staffing within the theatres recovery area when the unit had reached maximum capacity. When this occurred critical • There were five critical care consultants who provided care nurses were allocated to these patients as if they cover for the unit. The consultant on duty covered the were patients on the main critical care unit, adhering to critical care unit for seven days at a time; working the safe staffing recommendations. approximately 8am to 8pm, completing twice daily ward • There was usually one member of staff who was rounds and providing on call support for the overnight designated as the ‘runner’; they were not allocated to a staff. The provision of consultants on critical care was patient and were available to support staff breaks, compliant with recommendations from the Faculty of patient care tasks requiring more than one person and Intensive Care Medicine Core Standards for Intensive fetch equipment. Care Units. • Staff described the difficulties the critical care • Four associate specialist doctors supported the work of environment caused due to the single patient room the consultant on duty, with two working during the day layout and usually only having one ‘runner’ on shift. shift and one overnight. The associate specialist doctors Staff told us they sometimes had difficulties fitting lunch were senior registrar levels doctors who were not breaks into their day and often had to wait for a long currently employed under training programme. All time to be able to test a patient’s blood gas or get associate specialist doctors had advanced airway skills. equipment as they had to wait for the ‘runner’ to be • There was additional support for the consultant on duty available to watch their patient (especially if caring for a provided by a staff grade doctor on the daytime shift. level three patient). • Two medical handovers took place each day where the • Staff told us the layout and staffing levels also made it staff coming on duty received information about the difficult to get enough staff to turn patients, despite patients on the unit from staff finishing their shift. This using the health care assistant and nurse in charge to information contained all relevant medical information assist with this. We observed one member of staff as well as plans for the following days. waiting to test a patient’s arterial blood sample for over • When critical care was at maximum capacity and nine minutes because no other member of staff was patients were cared for within theatres recovery, the available to supervise the patient while the allocated critical care consultant reviewed these patients during nurse did the blood test. twice daily ward rounds as per best practice • The critical care outreach team was staffed by band recommendations. seven nurses and the team had recently increased its • We noted all doctors left the critical care unit to attend support to provide a 24 hour, seven days per week the weekly multidisciplinary meeting, leaving no doctor service. Where gaps appeared on the rota due to the immediately available on the unit. Staff told us this had increased service provision, senior band six critical care been risk assessed as acceptable as all doctors were nurses were used to fill these gaps after receiving available via a bleep, were not geographically far from outreach training. Agency nurses were used to backfill the unit and doctors were available within theatres, the shifts left vacant by the redeployed staff. adjacent to critical care should an emergency arise. The • At the time of our inspection, there were ten whole time Faculty of Intensive Care Medicine Core Standards for equivalent (WTE) band five and two WTE vacancies on Intensive Care Units advises critical care units must have the critical care unit. A recently approved business case immediate access to a practitioner with advanced meant there were also four new WTE band seven airway skills which iswas not adhered to in this vacancies within the critical care outreach team which circumstance. were being advertised at the time of our inspection. Major incident awareness and training

74 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• A copy of the hospital’s major incident plan was Evidence-based care and treatment available in paper format on the ward and on the • Clinical policies and procedures specific to the critical intranet via any trust computer. The plan highlighted the care unit were available on the intranet and some expectations of staff within different areas of the printed copies were available for reference on the ward. hospital and identified that critical care should expect to Additional trust-wide policies were also available on the receive additional patients in the event of an emergency intranet. Policies we reviewed were seen to have been which may mean sourcing additional staff who are off recently updated. duty or on leave if able. • An evidence-based ward round template was developed • Staff were aware of the major incident plan, however and used by some consultants responsible for critical staff we spoke with admitted they had not personally care. This template ensured a logical and thorough reviewed the document. They told us they would be approach to patient assessment during the ward round. guided by senior staff on the unit in the event of a major • The critical care unit used evidence-based protective incident being declared. lung ventilation with patients where appropriate and • Generator testing was completed on a weekly basis hospital audit data demonstrated 88% compliance with throughout the hospital and staff described how the this practice. critical care unit would receive a priority power supply • A ventilator-associated pneumonia (VAP) care bundle due to the acuity and complex mechanical was in use to reduce the risk of infection associated with requirements of patients on the unit. intubation and data from the North West London Critical Care Network between April and June 2015 Are critical care services effective? demonstrated 100% compliance with this, which was in line with other units in the local area. Good ––– • All patients receiving mechanical ventilation on the ward had end tidal carbon dioxide monitoring built into their ventilator settings. This was in line with Care provided on the critical care unit was effective and evidence-based recommendations from the Intensive patients achieved good outcomes, due to evidence-based Care Society. interventions provided by competent nursing and medical staff. The unit contributed to national and local quality • A central venous catheter (CVC) care bundle was used databases which meant their outcomes were benchmarked for the insertion and ongoing care of CVCs on the unit. against other units. Patient mortality was better than other Data from the North West London Critical Care Network similar units nationally and there were fewer early showed service compliance with CVC bundles was 96% admission deaths. Patient pain was regularly assessed and between April and June 2015, which was in line with well managed. other units in the critical care network. • The Visual Infusion Phlebitis (VIP) score was used on the Staff had good access to information, including data critical care unit to monitor the wellbeing of patient IV relating specifically to individual patients and also best lines, this was in line with best practice guidance. We practice guidance and research. Multidisciplinary team saw this documented in patient notes where (MDT) working was embedded and the weekly MDT appropriate. meeting worked well with involvement from a range of professions. Seven day services across the MDT were not • An evidence-based sepsis care bundle was in use in fully optimised and there was less than the recommended critical care and would be instigated on the hospital provision of dietetic support, however nutrition and wards by the critical care outreach team if appropriate. hydration was carefully monitored by nursing staff. • Patients with catheters received care based upon an evidence-based care bundle specifically designed to Staff demonstrated good levels of knowledge regarding the reduce the risk of catheter related urinary tract Mental Capacity Act. However understanding of consent infections. We observed use of this care bundle with all principles and the Deprivation of Liberty Safeguards was patients who had a catheter in place during our extremely variable, including amongst senior staff. inspection.

75 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• Faculty of Intensive Care Medicine Core Standards for cultural requirements, such as gluten free, vegetarian Intensive Care Units advise all patients should be and halal meat options. Special meals were made reviewed by an ITU consultant within 12 hours of available for patients who required certain textures of admission to ITU. Staff told us all patients admitted to food, for example pureed food or soft options. the unit would be reviewed by the ITU registrar or • We saw evidence that patients’ food intake was consultant prior to admission to the unit but time to monitored by nursing staff and this was recorded in the review by a consultant after admission was not formally patients’ daily care record. Staff told us it was important audited. to do this, along with monitoring the patients’ weight, to ensure they were taking in enough calories. Pain relief • Patients who were able to drink had a jug or cup of • All patients on critical care had their pain assessed on water left within reach. Hot drinks were also offered to an hourly basis when their routine observations were patients at regular intervals by nursing or catering staff. being completed. We saw evidence of this documented • Staff told us patients on a fluid restriction due to their on the daily care charts, other than when patients were clinical condition had their fluid intake and output asleep. closely monitored by nursing staff so their overall fluid • Patients who were able to communicate their pain level balance could be accurately calculated throughout the were asked to score their pain on a given scale and were day. We saw this in practice on the unit and staff were offered additional analgesia if appropriate. We observed able to demonstrate how the fluid balance was documentation showing this in patient records. calculated. • The Face, Legs, Activity, Cry, Consolability (FLACC) scale • Nasogastric (NG) tubes were inserted for patients who was used to assess pain in patients who were unable to had been identified as requiring enteral feeding. Staff communicate their pain. This scale used assessment of described tests which took place to ensure the tube had the patients' physical movements and responses to been inserted correctly, including a pH test and determine the level of the patient’s pain. We saw this completion of a chest x-ray. appropriately in use for unconscious patients on the Patient outcomes critical care unit. Staff told us they also used the FLACC scale with patients with a learning disability who might • The critical care unit contributed data to the ‘Intensive not be able to communicate their pain level. Care National Audit and Research Centre’ (©ICNARC) • Patients received pain relief via oral or intra-venous database for England, Wales and Northern Ireland. This medicines including patient controlled analgesia (PCA) meant care delivered and patient outcomes were and patient feedback suggested pain was well managed benchmarked against similar units nationally. ICNARC on the critical care unit. data quoted relates specifically to the period from January to June 2015. Nutrition and hydration • The critical care unit also contributed to the North West • There was 0.4WTE dietetic provision for the critical care London Critical Care Network which enabled further unit, which was insufficient to comply with outcome and quality benchmarking, specifically against recommendations from the British Dietetic Associate other local critical care units. and the Faculty of Intensive Care Medicine Core • There was an audit programme in place to ensure audits Standards for Intensive Care Units. The cover was of key performance criteria were completed at provided by a band seven or band eight critical care appropriate intervals, which was in line with trained dietician from Monday to Friday. Over the recommendations from the Faculty of Intensive Care weekend, nutritional support was instigated by nursing Medicine Core Standards for Intensive Care Units. staff if required. • ICNARC data demonstrated the percentage of patients • Patients who were able to eat were offered a choice of predicted to die during their critical care admission was food from the hospital menu three times per day. The higher than the UK average. Staff told us this was due to menu offered choices for people with specific dietary or the type of patients admitted to the unit. ICNARC

76 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

showed the mortality rate and standardised mortality • One full time practice development nurse (PDN) was in ratio were in line other similar units. According to post to support the learning needs of staff on the critical ICNARC data, there was a lower frequency of post unit care unit, which was in line with recommendations from hospital deaths than in other similar units. the Faculty of Intensive Care Medicine Core Standards • Fewer patients died within the first four hours of their for Intensive Care Units. The PDN also supported critical care admission than on other similar critical care student nurse placements and the development of the units according to ICNARC data. There were more critical care outreach team. patient deaths after seven days of critical care • The Faculty of Intensive Care Medicine Core Standards admission than on other similar units, although this was for Intensive Care Units recommends 50% of critical care an improving trend. nurses should be in possession of a post registration • According to ICNARC data, there were generally more award in critical care nursing. Additional critical care readmissions to critical care within 48 hours of nursing awards had been achieved by 80% of nursing discharge than in other critical care units, however data staff on the critical care unit. Data from the North West from the North West London Critical Care Network London Critical Care Network showed this was a higher showed the unit performed better than most other units proportion than most other critical care units in the in the local area between April and June 2015. local area. The PDN told us more nurses were booked to • ICNARC data demonstrated there were generally fewer complete the course in the next year. readmissions to critical care after 48 hours of discharge • Advertisements for internal and external training than in other similar units. courses were placed on a noticeboard outside the • Data provided by ICNARC showed approximately 30% of staffroom. Courses included venepuncture and patients discharged from the critical care unit cannulation, adult ventilation and Schwartz rounds. experienced a reduction in their level of independence Staff told us they were supported with opportunities for upon discharge from hospital, however almost all courses and additional qualifications. Two nurses we patients returned to their preadmission residence. spoke with told us they were booked to attend the adult • Between April and September 2015, four patients met ventilation course. the criteria for potential organ donors and two of these • Nursing staff told us they received ad hoc bedside eligible patients were referred to the specialist nurse for training from the duty consultant at times and valued organ donation (SNOD). Of these patients, one family this opportunity for learning. consented to organ donation. • Student nurses were allocated a junior and senior mentor and this information was displayed on the Competent staff student nurse information board. Details of weekly Nursing Staff: training sessions were also displayed. Students told us they were well supported by their mentors and received • New nurses on the unit initially worked as an excellent level of teaching and supervision. supernumerary members of staff, until their supervisor • Agency nurses received orientation to the critical care signed off a series of basic competencies. whichThis unit and told us they were well prepared to work on the meant they were then able to care for straight-forward unit. Competency checks were done by the nursing patients independently. For more complex patients or agency; and additional documentation was completed those with specialist nursing needs, more advanced during the agency nurse’s first shift on the unit by senior competencies had to be completed. For example, there staff to ensure they were working to the level required were a set of competencies concerned with the care of by the trust. One agency nurse told us they had last patients with a tracheostomy. worked on the unit four months previously and had not • Additional competencies were in place for band six and received another induction at the start of their shift that band seven staff which encompassed more managerial morning. Staff were unclear how frequently agency tasks such as staff management and shift leadership. nurses should be re-inducted if they had not worked on Staff told us competencies were used to guide their the unit for a period of time. learning and helped them to progress professionally. • Staff told us they had appraisals with their line manager, however few staff knew when their last appraisal took

77 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

place. Records showed appraisals were up to date for systematic approach to discussions within the MDT 48.33% of critical care staff. Senior staff told us this was meeting. The atmosphere was informal but productive lower than they wanted and had recently started a “big and encouraged constructive challenge from all push” to get to 75% by the end of 2015. attendees. Medical Staff • Physiotherapy staff worked closely with their nursing and medical colleagues to create rehabilitation plans to • New medical staff completed the generic trust induction address ventilator weaning (when patients’ reliability on which was attended by all new staff. In addition to this, breathing machines is reducing and they are able to do they were inducted specifically to critical care which more breathing on their own) as well as the physical included orientation to the unit and an overview of rehabilitation. Staff told us it was important patients got working practices, such as times of ward rounds and the sufficient rest between each of their daily activities and multidisciplinary meeting. Staff told us their transition so it was essential to communicate effectively with the onto the unit had been smooth and they were well multidisciplinary team. supported when they started working within critical care. • We noted the critical care team liaised with other critical • Junior doctors received three hours per week formal care centres, particularly specialist services, for training and had opportunities to lead sessions or guidance and advice regarding patient management. present research to the group. Staff told us ad hoc One staff member told us the critical care team were training sessions led by the consultants took place very open to help provided from other units and this frequently, such as in relation to a specific patient or process was invaluable for optimising patient care. certain medical condition(s). • Senior nursing staff described how they had worked • One consultant we spoke with was passionate about with ITU at Northwick Park Hospital and the trust tissue teaching and medical staff development. This viability teams to improve care of pressure sores. consultant was very keen for critical care at Ealing Seven-day services Hospital to receive specialist trainee doctors and to be recognised for the learning opportunities provided • Consultant-led ward rounds took place twice each day within the unit. including at weekends, which was in line with recommendations from the Faculty of Intensive Care Multidisciplinary working Medicine Core Standards for Intensive Care Units. • A multidisciplinary team (MDT) ward round took place Consultants were available on the ward throughout the each morning, with attendance from the medical team, day and provided on call support to the overnight nurse in charge and pharmacist as a minimum. Staff doctor, with a response time of 30 minutes. told us the ward therapists also attended when • The critical care outreach team was available via a bleep possible. We observed a ward round which facilitated referral system 24 hours per day, seven days per week. contribution from all members of the team where • Diagnostic imaging was available at all times within the appropriate. hospital, with an emergency on call bleep for out of • A weekly MDT meeting was held to discuss all patients hours cover. Staff told us there were no issues with on the critical care unit. This meeting was led by the accessing imaging at the weekends or out of hours. medical team and was also attended by the consultant • Physiotherapy was available from 8:30am to 4:45pm due to take over responsibility for the unit the following Monday to Friday, which offered a full rehabilitation and week. There were representatives from radiology, respiratory service. Over the weekend, respiratory pharmacy, infection control, infectious diseases, patients were reviewed by the on call team and some dietetics and microbiology. Staff told us the meeting rehabilitation patients would be seen if time allowed. was usually also attended by the critical care Out of hours, an on call physiotherapist was available to physiotherapy team. We observed a thorough and assist with urgent respiratory therapy with a 45 minute response time. • Staff told us there was little occupational therapy (OT) presence on the unit and most rehabilitation was

78 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

completed by the physiotherapists. We did not see an and also between the medical team. There was OT on the critical care unit during our inspection. Senior additional written information provided to the receiving staff described how they would like a greater area and the medical notes were transferred with the involvement of therapists on the ward to help patients patient. reach their potential more quickly. Consent, Mental Capacity Act and DoLS • Speech and language therapy (SALT) support was available from Monday to Friday via a bleep referral • Staff throughout critical care were aware of the system. Staff told us accessing SALT support could be principles of the Mental Capacity Act and understood difficult as they were “extremely busy” but they always patients should be presumed as having capacity until provided good support with tracheostomy patients. proven otherwise. One nurse explained how patients with capacity were able to make “unwise” decisions Access to information even if the decision potentially had unfavourable • We noted all patient notes were removed from the consequences,. fFor example, refusing blood thinning critical care for discussion during the weekly MDT medicines might cause a deep vein thrombosis. meeting. This meant notes would not be immediately However patients with capacity could make that available in the event of a medical emergency. Staff told decision and accept the risk of thrombosis. us this had been assessed as an acceptable risk as the • Staff knowledge of consent was variable within the notes were not geographically far from the unit and critical care unit. Some staff accurately described could be brought back quickly if needed. consent principles, including best interest decisions for • Patient investigation results, including blood tests and patients who did not have the capacity to consent to diagnostic imaging, were available on computer procedures; whereas other staff told us they would systems and were manually copied onto patient obtain consent from the patients’ families for invasive records, which could potentially cause errors during the procedures such as tracheostomies, which .u We transcribing process, although no incidents had been observed the correct consent forms were used where raised relating to this. required despite the variability in staff knowledge. • A cupboard on the unit entitled “ITU Library” contained • We observed staff asking patients for verbal consent various folders of information for staff. The ITU prior to interventions such as positional changes and Guidelines folder was divided into specific topics, such taking blood. Staff took care to explain why the as sepsis and ventilation, and contained trust policies intervention was required and we observed staff and other guidelines relating to patient care. Copies of explaining the risks of not completing the task. For the unit’s ICNARC reports were available along with a example, we observed a patient refuse to be turned in communication resources folder and information about the bed and so the nurse then explained it was caring for patients with a learning disability. necessary to prevent pressure sores which made the • The clinical lead consultant set up a reference web site patient change their mind and consent to the move. with copies of 5500 research articles split into relevant • Knowledge and understanding relating to Deprivation of critical care headings. This web site was accessible via Liberty Safeguards (DoLS) was variable on the critical log in and password system and all staff were able to care unit. Some senior staff on the unit told us they had access this if they wished. The consultant maintained never heard of DoLS and others explained the the web site independently and ensured data on the site implementation of DoLS on critical care was still “up for was kept up to date. Staff were very positive about this debate” and was not yet embedded on the unit. website and described it as “an extremely valuable • Substantive nursing staff generally had good knowledge resource”. of DoLS and were able to provide examples where • When patients were transferred to other units or applications had been submitted for certain patients. stepped down to a ward within the hospital, a verbal Agency staff on the ward told us they were not required handover took place between the relevant nursing staff to action DoLS requirements as they worked on the unit sporadically.

79 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• Relatives were confident about the care their loved one Are critical care services caring? was receiving on the unit and told us the staff always did “everything they can” to make sure patients get better Good ––– and had everything they need. • We saw evidence of many thank you cards and letters The critical care service was caring and supported patients which praised the service provided on the unit and the to be involved as partners in their care. Staff treated kindness of staff. Patients described staff as “stars” and patients with respect and compassion, and maintained expressed their gratitude for the care they received patient privacy and dignity during all interventions. Staff when admitted to the unit. helped patients and those close to them to cope • Our Short Observational Framework for Inspections emotionally with the care and treatments provided, (SOFI) demonstrated multiple positive interactions offering reassurance and encouragement when needed. between staff and patients, including asking patients Staff spent time providing explanations to patients and about their pain levels, fetching a blanket when the helping them to make decisions about their own care. patient was cold and usually explaining procedures before they were completed. We noted one negative Patient and relative feedback was positive. However some interaction where the patient’s dressing was changed comments on feedback forms suggested care was not without any explanation of the procedure. always at the level expected by patients. These comments • We observed a doctor providing an update about a were in the minority. We observed one example where a patient to their relatives within the main ward corridor, private conversation with relatives was held in the ward which was not an appropriate place for the conversation corridor which was not an appropriate space for this and and could compromise confidentiality. could compromise patient confidentiality. • Patient feedback forms were given to patients Compassionate care approaching the end of their critical care unit stay. Most comments on these forms were very positive. However • Patients provided positive feedback about all levels of there were some comments made suggesting the care staff on the critical care unit. They told us staff were received by patients was not up to the level they were friendly and made them feel as if “nothing is too much expecting and examples were provided, such as nursing trouble”. staff chatting over a patient when completing care tasks. • Staff addressed patients and their relatives respectfully and in a considerate manner. We observed staff chatting Understanding and involvement of patients and those to patients’ visitors and updating them about the close to them patients’ day, including any changes to their care. • We observed staff take the time to introduce themselves • Privacy and dignity was maintained by all staff involved to patients and their visitors, explaining their role and in patient care. We observed staff taking time to ensure why they had come to see the patient. Patients and their patients were suitably covered up when sitting out of relatives told us they appreciated this because it could bed in their chair and during physical assessments on be “difficult to remember who everyone is”. the medical ward round. Doors to patient rooms were • Patients and their relatives were involved in discussions kept closed and blinds were pulled down. about their care and we observed staff taking time to • Patients and their visitors told us staff were concerned thoroughly explain any changes in the patients’ medical for their comfort and offered extra pillows or blankets if condition and providing the opportunity for the patient needed. Patients told us staff asked about levels of pain or relative to ask questions. The medical team regularly and provided analgesia “reasonably quickly” communicated with patients about their intended plan when needed. of care and checked the patient was in agreement with • Staff spoke to unconscious patients when approaching their initial plan. Patients were encouraged to make the bedside and before completing any care tasks or decisions about their care and we observed staff interventions. We noted staff explained what they were describing more than one plan of care to the patient, going to do such as repositioning them even when there explaining the benefits of each and supporting the was no evidence the patient could hear. patient to decide which plan suited them best.

80 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• We noted patients were put at the centre of care during • The SNOD provided support for bereaved families where ward rounds and staff addressed the patients directly, appropriate and assisted them in obtaining certain including speaking withto unconscious patients who keepsakes from their loved ones such as a lock of hair could not communicate. and hand prints. • Relatives told us they were not asked to leave during the • Staff on the critical care unit told us they were aware of ward round unless specific physical assessments were external support organisations which could be accessed needed. They reported being involved in the care of the by patients and relatives if required. hHowever they patient. They said staff were always willing to answer were unable to provide examples when requested. Staff questions or find out information if they were not sure told us they would use the internet or the expertise of about something. their colleagues if they needed to signpost a patient or • Staff told us family meetings did not occur routinely but relative to a support service. could be booked in if families could only visit at specific times and wanted to meet with the medical team. Staff Are critical care services responsive? told us they would do “as much as possible to give relatives all the information” they wanted. Requires improvement ––– • A Specialist Nurse for Organ Donation (SNOD) was based on ITU and worked closely with the critical care team to identify potential organ donors. The SNOD was The responsiveness of the critical care unit required introduced to relatives of potential organ donors who improvement because services did not always meet had been told their loved one was dying and provided people’s needs. There was a shortfall in critical care information regarding organ donation. Staff told us the capacity and we noted occupancy rates were almost SNOD would remain involved in supporting relatives of always above 95%, which is considerably higher than the these patients whether they decided to allow organ recommended 70% critical care occupancy. We noted donation or not. some overflow of critical care patients into theatres recovery beds, although this only affected a small Emotional support proportion of patients and there had been no elective • Staff told us they offered emotional support as a matter procedure cancellations as a result of this. There were of routine and this was a key part of being a critical care more delayed discharges, and out of hours discharges from nurse. Staff told us patients and their visitors were often the critical care unit than in other units locally and much more stressed when they were on the critical care nationally, which staff attributed to difficulties with unit rather than a regular hospital ward because accessing ward beds within the hospital. We also noted a patients were much more unwell. They told us this high number of clinical transfers from critical care so meant staff had to be particularly sensitive to the patients could access specific treatments at other centres. emotional needs of everyone on the unit. There wasere no follow up clinics available to patients after • Patients told us staff were kind and sympathetic to their discharge from the unit and facilities for visitors were needs, empathising with their situation and offering limited. support when needed. One patient described being There was good support for patients who needed extremely nervous when having a CVC line removed and information in other languages as well as patients requiring told us staff were reassuring and encouraging during the psychiatric support and those with a learning disability. procedure. The patient told us a thorough explanation Patients and relatives could make informal complaints at was provided and staff “didn’t mind the extra hassle” of ward level or were supported to access patient advice and caring for a nervous patient. liaison services within the hospital to follow the formal • A chaplaincy service was available 24 hours per day, complaint pathway. There had been no complaints seven days per week. The team offered spiritual or recorded between April and October 2015. religious support to patients, relatives and staff members alike. Service planning and delivery to meet the needs of local people

81 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• The majority of admissions to the critical care unit were • Visiting times for unit were between 10am and 7pm, unplanned medical admissions (76% of patients). The with a one hour quiet period for patient lunch and rest. remaining 24% were patients admitted following Staff told us they allowed flexibility for families who had surgery, of which 58% were emergency cases and 42% difficulties visiting during the allocated times and this were elective procedures. was agreed and arranged on a case by case basis. • Difficulties in planning service delivery were identified • A small waiting area was provided for visitors to patients by staff due to the high number of unplanned on the critical care unit and we noted visitors over admissions from the hospital wards and emergency spilling into the corridor as there was not enough space department to critical care, which was difficult to in the waiting room at times. The waiting area was anticipate. located near the lift and stairwell area, away from the • Patients undergoing elective surgical procedures would unit. We observed visitors trying to access the critical usually have beds booked on the unit if the anaesthetist care unit and being told their relative would not be or surgeon caring for that individual judged the patient ready for visitors for another ten minutes and having to would require additional support postoperatively. Beds walk back to the waiting area. The same relatives had were booked with the critical care nurse in charge as far received no communication from staff 20 minutes later in advance of the patient’s admission as possible. and walked back to the unit for an update. We noted Critical care staff told us they allowed a maximum of 2 this could cause difficulties for visitors with mobility or booked admissions each day to allow for admission of other health difficulties. unplanned patients. • Information leaflets about the critical care unit were • Most patients (68%) who accessed the critical care unit provided at the entrance in several different languages required level three support and the remaining patients such as Urdu, Hindi and Punjabi. Other languages were required level two support. available upon request. • ICNARC data from January to June 2015 showed there • Staff demonstrated their awareness of the needs of were more clinical transfers out from the critical care different cultures and religions by describing how unit than in other similar units nationally. Staff told us differently certain groups viewed the management of some patients had to be transferred from the unit so dying patients as well the possibility of organ donation. they could access certain types of medical treatment, for Staff told us they respected the beliefs of different example extracorporeal membrane oxygenation cultures and religions but tried to do what was best for (ECMO), which were not offered in the critical care unit the patient and support the relatives accordingly. at Ealing Hospital. This was typical of the type of critical • Patients who were Jehovah’s Witnesses wore wrist care support provided within a district general hospital. bands which identified they should not be given any • No follow up clinic was provided for patients who had blood products, in line with their religious beliefs. been inpatients on the critical care unit, which was not • Psychiatric support for patients was provided by the in line with recommendations from the Faculty of psychiatric liaison team who reviewed patients Intensive Care Medicine Core Standards for Intensive demonstrating challenging behaviour, symptoms of Care Units. Senior staff on critical care were aware of the delirium and with any other mental health needs. need for a follow up clinic and said this would be a • One staff member told us about the ‘Treat Me Right!’ valuable addition to the service provided to the unit. initiative which ensured equal access to healthcare • No accommodation was provided for visitors to patients services for patients with a learning disability. They told on the critical care unit, even if they lived a long way us advice about caring for a patient with a learning from the hospital or had difficulties accessing the disability could be obtained from representatives within hospital via public transport. this organisation. In addition to this, staff told us they would seek support from senior members of the team, Meeting people’s individual needs as well as the individual patient’s friends, family and carers. One staff member told us they had made contact with a patient’s community learning disability support team to find out more about how best to communicate with that patient.

82 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

Access and flow this statistic due to the number of delayed discharges from the unit. However information from the North West • The North West London Critical Care Network data for London Critical Care Network showed length of stay was April to June 2015 demonstrated critical care at Ealing in line with other critical care units in the area. Hospital had a capacity shortfall in line with other units • Between January and June 2015, ICNARC data showed in the network. At the time of our inspection, there were the number of early discharges from the critical care no plans in place to address the shortfall in critical care unit was in line with other similar units. There were beds at the hospital. more delayed discharges from critical care than on • Occupancy of beds within the critical care unit was other similar units according to ICNARC data. Staff almost always above the optimum 70% capacity level explained delayed discharges occurred due to the identified by the Royal College of Anaesthetists. The availability of beds on the hospital wards. recommended occupancy rate allows for units to be • Patients discharged from critical care ‘out of hours’ able to take in more patients should there be an between 10pm and 7am are nationally associated with emergency. If a unit is at a higher occupancy, it is unable worse outcomes and ICNARC data from January to June to respond to emergency admissions and may find they 2015 demonstrated there were generally more out of are required to step-down patients too early or transfer hours discharges from critical care than in other similar patients to other hospitals out of their locality. units, although this improved on the last quarter of data Occupancy was usually at 95% and above 100% at collection to less than the national average. Data from times between July 2014 and January 2015. the North West London Critical Care Network showed • Staff told us it was sometimes necessary for the critical there were slightly more out of hours discharges than on care unit to overflow into the theatres recovery beds other critical care units in the local area. and this occurred more frequently over the winter • ICNARC data from January to June 2015 showed there months. Hospital data for January to July 2015 were more clinical transfers out from the critical care demonstrated this overflow affected 6% of critical care unit but less non-clinical transfers than on other similar patients admitted to the unit. units. Staff told us there were no non-clinical transfers • There were no elective theatre procedures cancelled during this period. between January and July 2015. Staff told us there used to be “several” cancellations each month but this had Learning from complaints and concerns now improved as patients would be nursed in the • Informal complaints were managed at ward level or theatres recovery area while waiting for a critical care patients and their families would be directed to the bed if needed. patient advice and liaison service PALS) within the trust • Faculty of Intensive Care Medicine Core Standards for to log formal complaints. Staff noted informal Intensive Care Units advises patients should be complaints via the incident reporting system. transferred to ITU within four hours of the decision to • We noted several posters throughout the unit, including admit. The critical care team told us this data began to within the visitors’ waiting area advertising the services be formally audited in October 2015. At the time of our of PALS and displaying contact details for this service. inspection, the admission of ten patients had been Staff told us they encouraged patients and their recorded and this showed 90% of patients were relatives to raise any issues or concerns as quickly as admitted in less than three hours which was in line with possible so they could be dealt with efficiently by staff recommendations. The remaining patient was admitted on the ward or escalated if appropriate. One staff to critical care after a wait of six hours and 15 minutes. member told us she had supported a patient to speak to Staff told us the unit was at maximum capacity when a PALS representative on the critical care ward. this patient needed admitting and so the delay was • There were no informal complaints logged by staff caused by making a suitable bed available. between April and October 2015 and no formal • Patients generally stayed on the critical care unit for complaints received via PALS during the same period. slightly longer than in other similar units, according to ICNARC data from January to June 2015. Staff attributed Are critical care services well-led?

83 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

including those who attend the emergency department. Although staff admitted to finding the prospect of a Good ––– merged unit disappointing, they highlighted the opportunities for research and quality improvement this The critical care unit was well-led and the leadership could bring. promoted the delivery of high quality person-centred care. • Staff on the ward were of the opinion that the future of There was uncertainty regarding the future of the critical the critical care service was “up in the air” and were care service, however the service management had unsure whether it would continue. They said the developed a vision and strategy to develop the service situation made them worry about their jobs and some within its current form, with an on-going focus on quality staff told us they did not want to be transferred to one of and safety. The measurement of quality was on-going we the other hospitals in the trust if critical care at Ealing saw some evidence of innovation such as the development Hospital was stopped. of the high flow oxygen service. Good governance • Senior staff were keen to stress they still had visions in processes were in place with dissemination of relevant place for the current critical care service. They explained information to the critical care staff; however there was they were very proud of their patient outcomes as well limited shared learning with other departments and across as their safety record and they were very keen to the critical care sites within the trust. improve both of these quality indicators through additional training of staff and development of practice. Staff were positive about the leadership of the critical care Staff described how more staff were booked to service and told us the department's managers were visible complete a critical care nursing course as well as other and approachable. The culture on the unit was one of courses and there was a big drive to complete openness and honesty, with constructive challenge appraisals and mandatory training to ensure staff welcomed. There was evidence of some staff engagement competence. within the service but limited public/patient involvement. • Senior staff reported that visions for the critical care unit We did not receive a copy of the departmental risk register had been developed in isolation without input or but staff told us the patient monitors were the only item on support from senior management within the trust. They the register; this was not appropriate and other issues were of the opinion that developments and investment identified during our inspection should have been listed for in the service would not be supported and had made example the high occupancy rates within the unit. There independent plans to ensure the service was continually were no strategies in place to address the high level of improving. occupancy and occasional overspill into the theatres • Ward staff were aware of the drive to continually recovery beds. improve the quality and safety of the service on the unit but told us they did not see a clear strategy for achieving Critical care management staff were vocal about their poor this due to the uncertainty surrounding Ealing Hospital’s relationship with trust management and reported that they future. had been forced to adopt methods of practice from the Northwick Park Hospital site following the merger. There Governance, risk management and quality was a sense of being undervalued as a department by trust measurement management and a lack of understanding about the • The governance processes for the critical care unit service provided by critical care. completely fulfilled the five requirements of governance Vision and strategy for this service quality measure as reported by the North West London Critical Care Network. • There was a feeling of uncertainty regarding the future • Monthly governance meetings explored the incidents of the critical care service at Ealing Hospital. Senior staff reported in the previous month and identified any described belief that the formation of one large critical trends. Actions to address trends were identified. care unit to cover all hospitals within the trust was inevitable. They told us the unit at Ealing had a lot to offer to the trust and to patients within Ealing Hospital,

84 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

Morbidity and mortality were also discussed, during • The medical and nursing leadership teams on the which the care of any patients who had died on the unit critical care unit were formed of several very was analysed to identify learning points and quality experienced members of staff, who had considerable improvement. critical care expertise. These members of senior staff • Governance issues were communicated to ward staff were allocated specific time to complete their during staff meetings and handovers if appropriate. leadership duties, including service development, Staff said they received sufficient information relating to governance and people management. Most staff said the governance processes on the unit. Senior staff told they had adequate time to fulfil their responsibilities. us they were always looking to improve the • Recommendations from the ‘Faculty of Intensive Care communication and consciously tried to make Medicine Core Standards for Intensive Care Units’ governance information engaging and relate it to case stating there must be a designated clinical director and studies to “help get the message across”. an identified lead nurse in critical care were met. • There was no evidence of shared learning between the Additional nursing leadership was provided by the critical care unit and other units within the hospital or supernumerary charge nurse on each shift. other areas of critical care within the trust. Senior staff • The critical care leadership team were vocal and honest told us this was a valuable and a wasted learning about the difficulties faced by the service at the time of opportunity, however neither department had our inspection. They demonstrated where actions were instigated processes to begin shared learning, in place to address these issues and acknowledged attributing this to resistance from their opposite where shortcomings within the service lay. number. • Senior staff described a disconnection between the • The departmental risk register was maintained by senior leadership of the critical care unit and senior staff on the critical care unit. We did not receive a copy management within the trust. Staff believed the trust of the risk register despite requesting it. However staff management had little understanding of the critical told us the only item it contained was the patient care service and made changes to practices throughout monitors which needed replacing. This would not the hospital without knowing any background accurately reflect our inspection findings, as we would information behind the decision. They described an also expect the capacity issues and potential closure of example where the number of overnight on call medical the unit to be listed as risks. staff in the hospital was reduced without any • The quality of the service provided by critical care was consultation with staff and this placed patient safety at measured continually and frequently benchmarked risk. The trust management was presented with data against the performance of other units via the ICNARC supporting the need for anthe additional on call person reports and critical care network quality measures and reinstated the post two weeks later. Staff said this report. Involvement in both benchmarking processes issue could have been avoided if there had been was well established and had been in place for several consultation with clinical teams within the hospital prior years. Quality of performance measuring data was to removing the on call post. analysed by ICNARC which ensured the information • Ward staff told us the critical care leadership team was quality reports were based upon were accurate, valid frequently visible on the wards and always and timely. approachable. Staff told us they would feel comfortable • Quality measures from ICNARC and the critical care raising any worries with the leadership team network were reviewed within quality meetings and believed their concerns would be listened to and attended by senior critical care staff on a quarterly basis. acted upon if necessary and possible. During this meeting unfavourable trends were identified and action plans for improvement identified. Culture within the service Additionally, areas of good performance were analysed • Ward staff reported feeling valued by the critical care to sustain quality. leadership team and believed successes on the unit Leadership of service were attributed to the team as a whole. They told us they were encouraged to have honest and open

85 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

conversations with other members of the team, additional feedback not covered by other questions on including challenging the medical management of the form. Feedback forms were compiled on a monthly patients if they disagreed with treatment plans. During basis and any themes were identified then disseminated the weekly MDT meeting, we noted a relaxed and to ward staff for praise or improvement plans as needed. friendly atmosphere which positively encouraged • Staff were engaged in decision making relating to unit constructive challenge and questioning from all changes by the critical care management team. For members of staff. example, as the old patient monitors required replacing, • Agency staff told us they were valued by their several new models were trialled and staff had the substantive colleagues and said they were made to feel opportunity to test each model and provide feedback like part of the permanent team, who were described as about their preferences. being friendly and welcoming. • Results from ICNARC reports were explained to staff to • Staff perceived that the merger with Northwick Park help them understand how the unit was performing in Hospital had been more like a takeover and described relation to other units nationally. Staff told us this how they had been made to adopt certain protocols helped with motivation and was useful to guide their based upon those used in critical care at Northwick Park focus on clinical care and performance. Hospital instead of their own. They were of the opinion • Staff achievements such as course completion or that this undermined their past performance and the promotion were reported in the trust newsletter which service provided by the critical care unit at Ealing was disseminated throughout the trust. Hospital. Acknowledgement of personal achievements were also • Senior critical care staff told us trust management identified during staff meetings. Staff told us they completed intermittent “walk arounds” where they appreciated their achievements being recognised and it would go onto the critical care unit. Staff told us they made them feel proud. did not value these visits and felt they received undue Innovation, improvement and sustainability criticism and little praise afterwards. • Some senior critical care staff were hesitant to raise • Staff described hopes to further develop a high flow concerns with senior trust staff as they were concerned oxygen service which would be overseen by critical care about the repercussions this might cause. Staff said they staff but delivered on the medical wards. Staff felt this sometimes used a colleague as a ‘spokesperson’ to raise additional level of ward treatment might help reduce issues, with support from the senior critical care team. medical admission and help offset some of the capacity • We were told of recent resignations from senior critical issues. care staff and we saw evidence suggesting the reasons • A business case had recently been approved by the trust for resignations were largely due to the perceived poor to increase the provision of critical care outreach in the relationship between the critical care service and senior hospital to 24 hours per day, seven days per week. Staff management within the trust. told us this would enable them to appoint new • Senior critical care staff told us they valued their substantive outreach staff and reduce the use of agency colleagues and had good working relationships on the staff on critical care due to the use of ward staff to unit. They felt these good relationships did not extend backfill the outreach shifts. to the critical care team at Northwick Park Hospital and • Staff described the need for a critical care follow up told us there was very little interaction between the clinic but explained no steps had been taken yet to put units. this service in place. Staff told us they felt it was unlikely to be supported by the trust as the needs of critical care Public and staff engagement patients were not understood by senior management. • Patient feedback was obtained via feedback forms • Senior staff described their hopes of having specialist specific to the unit. Patients and their relatives had the trainee doctors in post on the unit and having the unit opportunity to rate a number of different aspects of the formally acknowledged as a training location. Staff were care on the unit and a free text comment box for any passionate about educating junior doctors and felt there were suitable learning opportunities within critical care for it to be a valuable placement.

86 Ealing Hospital Quality Report 21/06/2016 Critic al c ar e

Critical care

• Some cost saving initiatives were in place on the unit, reduced in an effort to get staff “out of the office and for example senior staff described how the consumable onto the shop floor”. Staff were supportive of this procurement process had been streamlined and a list of change and did not feel this had had a detrimental approved suppliers provided to keep costs down. Staff effect on their ward management role. told us senior staff management time had also been

87 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

Safe Requires improvement –––

Effective Good –––

Caring Good –––

Responsive Requires improvement –––

Well-led Good –––

Overall Requires improvement –––

Information about the service Summary of findings Ealing Hospital has one inpatient 20-bedded ward on level Children and young people’s services overall requires 10 named ‘Charlie Chaplin’, which has a secure playground improvement but the service is considered good for on the roof terrace for children to play and a conservatory caring. We found out of date policies still in use, Control for parents to relax. Children and young people with a of Substances Hazardous to Health (COSHH) variety of medical and surgical related conditions between assessments not completed and chemicals found the ages of nought and 16 years are cared for on the ward. stored in an unlocked cupboard in an unlocked cleaning Princess Amelia Ward is the 6 bed day care unit (based on room in the children’s ward. level 10 opposite Charlie Chaplin ward), where children and There were staff shortages in some areas with a high use young people having minor operations, special of agency or bank staff covering for sickness and investigations and treatments, are cared for. additional leave. There was evidence of some There is a designated paediatric resuscitation area in the transitional arrangements for moving children from emergency department and a 4-bed Clinical Decisions area children into young adult then adult care. Senior staff dedicated to children. had to seek out numbers when children were admitted to an adult bed, as there was no flagging system. We spoke with 6 children and their parents or guardian, 23 staff including nursing staff,medical staff, play specialists, There were gaps in support arrangements for children ward housekeepers and administrative and managerial with long term conditions e.g. epilepsy and no identified staff. nurse specialist to support this group of patients who required information and support with this potentially We reviewed 10 sets of patient medical and nursing records life changing development. and information requested by us and provided from the trust. The service was not responsive to meeting the needs of children and young people when in the children’s We inspected all the areas above including the transition accident and emergency department as the waiting arrangements for children transferring into adult services time was reported as too long by parents seen. The and the provision of care for children with long term children’s waiting times data was requested from the conditions such as diabtes, epilepsy and asthma. trust but not received.

88 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

We were informed of the future change for the service Are services for children and young which had been developed. Eight staff were spoken to by the inspectors of which two staff members were not people safe? aware of the local or trust strategy. Requires improvement ––– The arrangements for governance and performance management did not always work effectively as items Safety of the children’s service required on the risk register did not reflect all the areas that improvement. Although the safeguarding children’s require improvement identified by the inspectors. These procedures were embedded and robust, other policies and risks were dealt with immediately when raised by the procedures required review and updating. The inspectors. safeguarding children’s policy was also currently under Leadership within the service was rated as requiring review and the existing out of date policy was seen as a improvement. Staff informed us that managers had not printed hardcopy across the service. always been visible on this site since the movement of We found out of date policies still in use, Control of managers to the Northwick Park site. Substances Hazardous to Health (COSHH) assessments not The safeguarding children’s procedures were robust completed and chemicals found stored in an unlocked with staff demonstrating how they were embedded into cupboard in an unlocked cleaning room in the children’s the service. ward. Feedback from all family members and children or There were staffing shortages for registered staff across the young people we spoke with was positive about the service with excessive use of agency staff in July and care provided. Parents said that staff were enthusiastic August 2015. We had been informed that recruitment was a with providing care for their children and staff engaged problem with the future commissioning changes with the children and parents in individualised plans of care. service. Work was needed to stabilise the staffing base and reduce staff sickness. We saw the electronic roster for the 93% of children were seen within 18 weeks of referral for past month and were told by staff who had worked extra treatment. Services were planned and delivered to meet bank hours. That they worked these extra hours on top of the needs of the diverse population. their permanent contracts to reduce the need for agency There was an accident and emergency escalation policy staff. for paediatrics which was designed to prevent excessive There was good evidence of record keeping and waiting times for children. completing paediatric early warning signs (PEWS). Incidents • One never event had been reported in children’s accident and emergency when the registered children’s nurse (RSCN) was escorting a seriously ill child to the other acute site. This resulted in an eight-week-old baby being given an oral dose of antibiotic intravenously by an adult trained nurse not following the medication policy. “Never events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.” • The children’s service reported 32 serious incidents (NRLS) through the online reporting system, called Datix

89 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

between June and September 2015. The most common • The ward’s quality board gave an example where a reported incidents were staffing levels not meeting child’s care did not go as planned and the additional children’s acuity or dependency and issues with the training provided for staff to reduce the risk of administration and recording of medicines. reoccurrence. • We saw 871 incidents reported since August 2015 across Cleanliness, infection control and hygiene this integrated service. The identified incidents related to staffing, discharge letters and interpreters not present • There were strict processes in place to prevent the which led to a cancelled appointment. We saw no potential spread of methicillin resistant staphylococcus evidence of sharing lessons learned across the trust. aureus (MRSA). Testing for MRSA was standard, if a child • oftenminimal.We reviewed several incidents reported had previously tested as positive, they were nursed in a for this service through the Datix electronic reporting side room until two negative results had been obtained. system with the root cause analysis and completed • Monthly infection prevention and control (IPAC) audits recommendations. On review of the incident reports took place across this service The audit included hand submitted, the action taken in response following an hygiene, standard precautions, care of peripheral investigation was often not detailed and not presented vascular device insertion and continuing care, patient in ‘SMART’ style. One example was when an agency staff equipment and environment. Methicillin Resistant member did not turn up for a shift. The action was that Staphylococcus Aureus and Clostridium difficile audits the nurse in charge persuaded a permanent member of were completed monthly and displayed. Cleaning staff to cover the shift but the record did not state scores for each ward from local audits were compliant. actions taken by temporary staffing with the However, there was limited evidence of cleaning management of the agency. schedules across the service. • We reviewed the ward meeting minutes for July and • A monthly infection prevention and control safety cross August 2015 and there was no record of incidents or was on display across the service. The cross shared learning seen. demonstrated how many days the ward had been free • Staff we spoke to were aware of the requirements of of infection outbreaks for MRSA and clostridium difficile reporting incidents and when and how to complete an (CDiff) that month. In this case, every day had been free incident reporting form. of these healthcare acquired infections. There have • Incident reporting and learning was shared across the been no reported cases of identified for children’s and service and the wider trust. Staff minutes confirmed the young people’s services. Datix reporting system had merged as expected in • Staff during the inspection at this hospital were October 2015. compliant with “bare below the elbows practice” and • There were incidents seen that met the requirements of wore their uniform with new lanyards and badges in line Duty of Candour. Staff were able to articulate the with the trust merger senior staff uniforms were different requirements of Duty of Candour and actions taken to Northwick Park staff in the equivalent role when this had been completed. Senior staff confirmed Compliance with key trust policies was observed and an that they spoke with families involved in incidents when internal audit stated a 100% Hand Hygiene compliance appropriate as part of the standard practice of being level. open following an incident • When asking two members of staff to identify the • The medical and nursing staff in the service attended infection prevention and control lead for their area, they mortality and morbidity meetings currently held were not able to do so. monthly with ‘everyone welcome’ to a Skype link • Disposable curtains were in use but on Princess Amelia meeting. The last meeting was held in September 2015; day care unit, torn adhesive labels were attached, those minutes demonstrated that the Skype link showing four curtained areas replaced on 7 Oct 2015. information technology system stopped working during • Eight Chloriclean tablets containers were found in an the meeting unlocked cupboard in an unlocked housekeeping room opposite the children’s four-bedded bay on Charlie Chaplin ward. This issue was resolved immediately,

90 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

once inspectors brought this to the attention of senior • The bath situated in the first washroom on Princess staff. Senior managers reviewed and reduced stock Amelia was badly stained and we were informed by levels, which are now in a locked cupboard and senior staff that it had been recently reported for obtained a key for the cupboard on the ward, which we replacement. There was no signage showing “Not in were assured would remain locked. use”. • The schoolroom appeared well equipped and captured Environment and equipment the educational needs of children and young people of • The environment on leaving the lift at level 10 was clean a mixed age range. and free of any clutter The entrance to level 10 ‘Charlie • The conservatory and outdoor play area were “tired” in Chaplin’ children’s ward area was secure The entrance appearance, we saw broken storage containers and to level 10 ‘Princess Amelia’ day ward area had flooring that was stained from the elements. automatic opening doors with CCTV in position across Medicines four points of the corridor. • CAMHS patient quiet room on Princess Amelia had no • We observed a ward medication round which was call bell, nor any evidence of risk assessment completed completed by two RGNs wearing red tabards with “Do to support staff safety when dealing with potentially not disturb I am completing a drug round”. Two staff aggressive children members expressed concerns that they still had • Clinell “I am clean” green stickers were used on occasions to stop during the medication rounds if equipment and seen across the service staffing levels meant no other staff on ward were able to • Resuscitation equipment was checked daily with assist parents or children. completed checklists in place. • Antibiotic compliance was observed and checked daily • Equipment was found to be clean and where required by the children’s specialist pharmacist. an electrical safety test was completed and labelled to • We checked six prescription forms, which were show when the equipment was checked as safe. completed including weight, height and identified • Bed mattresses examined were new with no visible allergies noted. soiling. The process of when they were checked was • The Children’s specialist pharmacist informed us identified. Some beds seen were numbered but we were she was due to leave the following week and senior staff not told why all beds did not have this system. This could not confirm how this service would be covered. means that some beds could be missed with Records maintenance checks. • Equipment was stored in the OP cubicle area with only • Children had risk assessments completed on admission, one piece of equipment having a completed which were evidenced in the six patient records decontamination form. examined. • A fridge containing staff food on Princess Amelia was • We saw completed care plans, which were updated and found with no temperature recordings since Sept 2015. included pain scores. Senior staff we discussed this with said they were not • We were informed that GP discharge letters were sent aware of who was responsible for this check. Senior staff out electronically but with the recent introduction of informed us this is now undertaken by the housekeeper. System[EG3]One, senior staff confirmed that they had • A parent’s fridge on Charlie Chaplin had no not yet received training System One is a centrally temperatures recordings for September, although daily hosted clinical computer system developed as one of recordings were completed for October showing the accredited systems in the government’s programme temperature was 2-5 degree Celsius, which is within the of modernising information technology in the NHS. accepted normal range. • Hospital numbers were not recorded on every page of • Non-disposable blood pressure cuffs were seen in use, the medical records and a recent internal audit staff assured us that cleaning had occurred between confirmed that only 64% of the notes were compliant. patient use. • All COSHH assessments seen were out of date with the • The Charlie Chaplin ward and CDU was secure entry by last assessment completed in 2005. The trust had card to give restricted access updated its policy and changed the process in August.

91 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

Senior staff were unable to describe their • Between April 2014 and March 2015, the service had responsibilities following this change, with the recent undertaken 6,660 children’s safeguarding consultations withdrawal of the information technology system called for referrals for child protection plans. This data was Sybol requested but not mentioned in the safeguarding annual report received. Safeguarding • This service had a process for flagging up safeguarding • The safeguarding children’s policy is currently under children via I.T. on entry to the trust review and the existing out of date policy was seen as a printed hardcopy across the service. Mandatory training • The acute safeguarding groups report into the women • The trust target for attending mandatory training is 95% and children’s health directorate and inform other with staff from children’s services achieving 80%. directorates as and when information from safeguarding Training for HCA completing mandatory training 78%. IV is pertinent to a directorate update training for staff was 80%. Infection control • The trust had a safeguarding children strategic group, training compliance achieved was 78%. which reported to the Trust Board. • The organisation migrated from Wired in March 2015 to • Monthly safeguarding meetings and a quarterly Education and Learning Management System (ELMS). operational meeting took place in sub-divisions. ELMS provides staff with the opportunity to book their Information from these was shared with the Clinical training electronically, record data and produce reports Performance and Patient Experience Committee. Child Sexual Exploitation and Female Genital Mutilation were Assessing and responding to patient risk amongst the areas covered by the strategic group. • The use of the paediatric early warning tools were seen • We reviewed the first quarterly report for Safeguarding in six children’s records and were completed correctly in Children, which related to the period April 2015 to June line with national guidance for PEWS. Staff were able to 2015. Information included: review of child deaths, describe when they escalated a deteriorating child and (none at Ealing Hospital for the quarter), priority areas of actions taken. work, training figures and governance and • Staff confirmed they used the “SBAR” tool across the accountabilities. service. SBAR is a tool to use to ensure communication • Safeguarding supervision was well established within is effective when handing over or communicating with the organisation. All paediatric nurses are able to access another healthcare professional about a process. one to one supervision every three months. • Senior staff informed us that it was planned to extend • Staff we spoke with described the referral process and the service provided by the rapid access clinic in future knew the names of the safeguarding doctor and lead to seven days to support children and reduce A&E nurse. waiting times by enabling Ealing GPs to refer to a • The information technology patient system did not flag paediatrician. up any “at risk” children or children admitted across the • Staff attended advanced paediatric and neonatal life hospital on an adult ward. Senior staff confirmed that support training with 80% compliance across this admissions were physically sought through the site service. management team. • Child protection issues were discussed at staff handover Nursing staffing and with the wider team. • The children’s service vacancy for registered nurses was • Safeguarding training for staff was 68% at level three, one whole time equivalent (WTE) band 7 and three WTE 60% had received the training for level two and 97% of for support staff. Ealing had 16.66 WTE registered nurses staff had been trained at level one as evidenced in the (RGN)in June 2015 down from 20.66 WTE in Oct safeguarding children’s annual report. Within outpatient 2014.Charlie Chaplin ward band 7 vacancy was covered services, 89% of staff had received safeguarding training by matron. at level three. This was against a trust target of 95%.

92 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

• The RCN ( Royal College of Nursing) acuity tool for safer • The children’s service would respond to the trust major staffing was used but senior staff confirmed there was incident and business continuity plans on the trust difficulty in recruiting to the hospital. intranet Staff had access to this information and senior • August and September 2015 safer staffing levels showed staff knew they had action cards to follow. that the permanent RGN to bed ratio for day and night • When speaking to the inspectors, staff described a was 1:6 higher than the recommended 1:4 ratio for this recent experience of preparing to evacuate the ward service. area and actions taken. There was no evidence seen • The staff handover demonstrated a comprehensive that a complete drill had been completed or that a approach. recent formal practice had taken place. • Skill mix details submitted via unify in line with safer • We saw the evacuation plan on the ward, no date was staffing ratio was 70% RGN to 30% HCA. on the plan. This was brought to the attention of senior • Bank staff came through existing team members staff. working through the bank system (including induction processes for these staff groups) Are services for children and young • The electronic roster version 10 is used which links to temporary workforce. This meant there was no delay people effective? once staff amended the roster. • We were told by senior staff that the trust were aiming to Good ––– reduce agency staffing cover but currently, due to maternity and sickness leave, shift requests to fulfil We rated the service good in effectiveness. There was staffing levels were covered by bank or agency staffing. evidence of children and young people with good Senior staff informed us this was covered by bank and outcomes because they receive effective care and agency staff who had worked on the ward before. treatment. • We saw that staff were working bank shifts in addition to Children and young people have comprehensive their own shifts to avoid the use of agency staff assessments of their needs, which include clinical needs, Medical staffing mental health, physical health and wellbeing and nutrition and hydration needs. • We were informed there were 5.7 WTE consultant paediatricians for the service but there was difficulty in There was participation in local and national audit, recruiting. There was one WTE vacancy. We requested including clinical audits and other monitoring activities, information regarding staffing of other doctor grades including peer review. This service recently participated in but did not receive this. the national clinical audit for the initial management of the • There was one locum middle grade and one locum fitting child. The Royal College of Emergency Medicine working at Ealing in this service. (RCEM) standards were met except for standard 4, in which • The paediatric consultants were available on site 0% was given (there was no written information from the Monday to Friday with consultant cover provided on child or parents). Saturday and Sunday. During times when a consultant Staff were qualified and had the skills they need to carry was not on site, there was a 24 hour on-call service out their roles effectively in line with best practice. The available learning needs of staff are identified and training is in place • Medical staff spoken to confirmed consultants were to meet these learning needs. supportive and accessible out of hours and at weekends • A medical handover was observed and was well Most care and treatment reflected current evidence based structured, open and comprehensive. All staff present guidance, standards and best practice. However, the were engaged and concerns raised were addressed. children’s day care unit surgery document did not. It was last updated in 2003 and codeine remained in the Major incident awareness and training

93 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people analgesic ladder, which does not follow national guidance • We spoke with four children and six relatives and all for children. The post-operative care plan did not include confirmed that pain relief was managed and monitored paediatric early warning system (PEWS). We were informed to promote successful pain management. this was now added to the care plan. • Four staff confirmed that they had no difficulties when requesting further pain relief prescriptions for children. Staff are supported to deliver effective care and treatment, • We saw an outstanding diversional therapy approach for including through supervision and appraisal. children and young people, which was led by the play Consent to care and treatment was obtained in line with specialist and school tutor. legislation and guidance. Staff were able to demonstrate a • The schoolroom provided an area for children to receive good understanding of the Gillick competence and children schooling, listen to recitals and additional diversional were supported to make decisions where appropriate. therapy to overcome hospitalisation. Parents were also supported to make decisions where appropriate and offered information to make best interest Nutrition and hydration decisions for their child in respect of treatment. The Gillick • Children spoken to by the inspectors stated that they competence is a test in medical law to decide whether a enjoyed the food offered. child of 16 or younger is competent to consent to medical • Dietician support was accessed as required. The examination or treatment without the need for parental dietician was easily accessible and recorded in the permission or knowledge. children’s notes with reviews updated as completed. . Evidence-based care and treatment • Fluids offered were documented on the children’s fluid input chart. • Care was provided to children and young people in • Weights of children were monitored with clear care accordance with national guidance, including guidance plans of how the service would meet the needs of the from the National Institute for Health and Care child. Excellence (NICE) and the Royal College of Paediatrics • The patient led assessment in a clinical environment and Child Health (RCPH)Policies are based on NICE/ (PLACE) was scored at 92% for food, which is above the Royal College guidelines but although evidence was England average of 90% PLACE inspection results seen of recent activity in reviewing policy and guidance, reflected the introduction of steamplicity with a there was currently no updated abduction policy. separate children’s menu children; parents concurred Evidence was seen of a draft policy but this meant that that the food was good staff were unlikely to be aware of this trust-updated policy. Patient outcomes • Staff had access to all guidance, policies and • The CQC reviews the information provided by trusts to procedures, which were available on the trust intranet. assess if the service has a higher mortality rate for • Appropriate care pathways were in place for children patients with different conditions. These are called with long term conditions e.g. asthma or diabetes. outliers if they are outside of the national rates. There • Local audit activity was seen with the results displayed are no open CQC outliers for this service. at the entrance or at a focal point for parents within • The median length of stay was mixed with one indicator Princess Amelia. A comprehensive audit was reviewed below the England average, one above the England for medical records showing improvements for 2014-15 average and two the same ( June 2015). when 61 randomised records were audited • The rate of multiple emergency admissions within 12 Pain relief months for epilepsy was higher than the England average. • We examined the records of patients across level 10 for • The proportion with HbA1c is lower than 7.5%, which is this service and observed that they used a child specific lower than the England average. Median HbA1c levels pain monitoring score. Pain scores were recorded which for patients are higher. were then monitored by staff during observational or • This hospital recently participated in the national care rounds when further pain relief was offered. clinical audit for “the initial management of the fitting

94 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

child”. The Royal College of Emergency Medicine (RCEM) • We observed that staff across this service worked standards were met, except for standard four in which effectively together and with the children’s community 0% was given as there was no written information for services. the child or parents. • We observed the handover of the care of a child with • Paediatric asthma audits performance had been multidisciplinary discussions and care pathways developed this year in line with the commissioners and completed. The communications observed between an agreed CQUIN scheme seven to reduce the doctor and nurse was professional and followed the proportion of avoidable emergency admissions to SBAR style. hospital, which improves care for children with asthma. • Care and treatment plans were completed and This project will develop community led specialist discussed with children and their parents. services for children with asthma and is supported by • Staff we spoke to confirmed there were good working acute clinicians and expert general practitioners. The relationships between themselves and other programme is on track to meet quarter one professionals. requirements. This programme has included setting up • We observed a presentation from a study day promoting educational programmes for staff, children and parents the work of the transition to adult services. We were with the support of an asthma specialist nurse in informed that there was no flagging system to identify accident and emergency department. . any children or young person admitted to an adult • The paediatric diabetes audit performance report was ward. Senior staff spoke regularly with the operational not received. site team to confirm admissions The service had no • The emergency readmission rates within 2 days of updated policy for the transition of children into adult discharge is better than the England average for services. non-elective and elective admissions. • Access to psychiatric and psychology services was • The record keeping audit submitted showed that 48% of available through the child and adolescent mental patients are not seen by a consultant within the first 24 health services (CAMHS). We were informed of examples hours following admission. This data is currently not of when these services had been used and staff reported comparable through information held by CQC analysts. a good working relationship with these teams. The quiet room identified for interviewing children on Princess Competent staff Amelia was well situated but had no call bell facility if a • Across children’s services, 85% of staff had received an staff member needed to summon assistance. appraisal within the last year We spoke with the matron Seven-day services who confirmed there was a clear plan to complete the remaining staff appraisals except for those who • The level 10 children’s service has consultant ward remained on maternity or sick leave. rounds seven days a week and the consultants were • Supervisory sessions were held with staff but we were available outside of normal working hours through the not assured that these were prioritised with the current on call weekend rota and on call system. high level of agency and bank staff. • The pharmacy department was open Monday to Friday, • Throughout this service, revalidation for nursing staff in with on call arrangements for weekends and outside line with Nursing and Midwifery Council requirements is normal hours on weekdays. supported by senior staff. • The support services for this service e.g. imaging • Revalidation for all medical staff had been undertaken services, occupational therapy and physiotherapy were for 100% of medical staff. The clinical director confirmed available Monday to Friday, with out of hours that dates have been set for any outstanding appraisals arrangements supported by an on call system. • The trust wide spiritual care and chaplaincy team were Multidisciplinary working available for pastoral support for children, their families • Multidisciplinary meetings were held weekly. Staff were and staff. This service was available 24 hours a day, 7 motivated and passionate about providing children and days a week via an on call system. young people with a good patient experience as the Access to information service changed.

95 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

• Staff had access to all main computers, including test • We observed all areas of the children and young results, diagnostics and patient record systems. people’s service, listened to groups of staff and • Procedures were all available through the intranet and individuals who were involved in patient care and found there computer points across the service to support that staff responded appropriately and supported them staff. to meet their needs. • We saw good interactions between staff, children and Consent families. • Staff we interviewed were aware of the guidance with • All parents we spoke with during the inspection told us obtaining consent and the Gillick competence Staff were that they had been treated with respect and dignity by able to demonstrate a good understanding of the Gillick the staff. competency and children were supported to make • The following comments were collated: “All staff are decisions where appropriate. friendly; neat and clean helpful staff and polite natured; • Parents were also supported to make decisions where its good care; friendly attentive staff who made me feel appropriate and offered information to make best welcome; staff went beyond what I expected when interest decisions for their child in respect of treatment. caring for my child”. • Parents were seen to be involved in the decision-making • The CQC undertook a children’s survey in 2014. We processes regarding care. Leaflets were available for asked children and young people, their parents and parents who were making decisions about providing carers, to answer questions about different aspects of consent to surgery. their care and treatment. The trust scored about the same as other trusts in relation to C1. “Are people Are services for children and young treated with kindness, dignity, respect and compassion people caring? while they receive care and treatment?” • We saw patient feedback information on the care of children and young people through the NHS Choices Good ––– patient forum. Comments were mostly positive but, there was no acknowledgement or response from the The services for children and young people are rated as hospital to these comments. good. Feedback from all family members and children we • Friends and Family Test results seen for April 2015 spoke with during the inspection were positive about how showed the following scores for patient’s or parents that the care was provided. The parents stated that the staff would recommend this hospital: Charlie Chaplin’s ward went beyond what they expected them to do for their 91%, Princess Amelia day-care 100% and children’s children. outpatients 95%. • The rate of compliments received by the service We observed good interactions between staff and children demonstrated that children and young people and their during our inspection. Staff showed respect protecting families thought that the care was good. children and young people’s dignity and privacy across the • Thank you cards were seen on the boards in ward areas service. Children appeared to get on well with staff and staff described informal thanks had been received members when we observed them interacting with them from grateful families. during the inspection. • Children’s stories about their experience of care were Children and their parent’s emotional needs were also displayed on the ward for other children and families to recognised with support from specialist staff, chaplaincy read, which was positive. and counselling services available. Understanding and involvement of patients and those Children and their parents were active partners in their close to them care. • The play specialists in this service were outstanding and Compassionate care demonstrated how they could make a difference to the service and its environment in meeting the needs of the children and young people. We saw examples of

96 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

diversional therapy sessions, papier-mâché sculpting, conditions, including those for epilepsy, were clear. There heard about recitals and across the ward, posters were were identified gaps in management resources for this designed for everyone to view the life and hobbies of area.We saw no policy for transition from child to adult the original Princess Amelia care. • Parents we spoke with told us that they were informed The multiple admission rate for children was 48%, which about their care and could ask any questions of the was above the England average (17.4%). doctors or nurses The facilities available to families enabled them to stay and Emotional support met their needs when supporting their children. • Staff gave examples of how they were able to access The children had indoor and outdoor play areas. The support and training they received for breaking bad outdoor play area needed a refresh as it looked tired with news. broken storage boxes and water leaks around the area. • Clinical nurses for children specialities including oncology and learning disabilities supported staff, The service had responded to the needs of families with children and families when required. arrangements to meet the diverse language needs of the • We saw evidence of teaching at the bedside for those population served by this hospital. There were leaflets for children who could not access the school room. The families in a variety of languages and staff were able to teacher was very experienced and long term patients identify how to access a translator with staff identified were well known to her. across the trust where English is not the first language. • Assessments for anxiety were completed as part of the admission process within this service. Service planning and delivery to meet the needs of • The trust counselling services could be accessed as local people requested during the working week Monday to Friday. • The shaping a healthier future (SaHF) programme • The trust wide spiritual care and chaplaincy team were identified the removal of children’s inpatient and available for pastoral support for children, their families children’s emergency department from this hospital and staff. This was available 24 hours a day via an from June 2016.A general practitioners paediatric on-call system. support service is to be introduced on this site.This • Schwartz rounds commenced in the trust eight months support service will also promote the out of hospital ago and senior staff from this service had attended. service. There was no evidence of paediatric cases discussed • The post surgery recovery area environment was not suitably planned and arranged for the needs of children. Are services for children and young Children were recovered in the same area as adults as people responsive? there was no dedicated paediatric area. • There was a range of leaflets available in ward and clinic Requires improvement ––– areas. Access and flow The responsiveness for children and young people’s service required improvement. The service was not always • Thirty-nine of the elective admissions (28%) among planned to be responsive to meeting the needs of children children in the under two year age group and 101 (72%) and young people with excessive waiting times. The service of the elective admissions in the above two year to 17 was achieving 73% of patients being seen within 18 weeks age group had a length of stay of one day. of referral for treatment. • The multiple admission rate for children was 48%, which was above the England average (17.4%). The transitional arrangements for moving a child from • Bed occupancy was 85% with admissions to children’s children’s care into young adult care before moving into ward between April and July 2015. Cases totalled was adult care services was identified as an area for further evidenced as 859 but there were two gaps in the data development as not all pathways of care for long-term received.

97 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

• Ambulatory care service was through the Princess • We saw DVDs and electronic games as well as board Amelia day care unit. There was a waiting area and side games to meet the varied needs of this service. We saw rooms. This service was being reviewed in line with toys, books and other items for children to use during service changes in June 2016. their stay in hospital. • Children who attend the hospital in an emergency were • Parents of children were able to stay on the ward near seen in the children’s emergency department where if, the child to support them and we saw a bed chair in after being seen by a specialist doctor and they required use. admission, would be transferred to the children’s ward • There were side rooms where private conversations as soon as possible for specialist care. could take place away from the main ward environment • Children’s outpatients department dashboard showed to ensure privacy was maintained. total new outpatient activity as 669-978 between April Learning from complaints and concerns and August 2015. In the same period do not attends (DNA’s) were between 101-238 each month which gives • The trust provided a ‘listening, responding and a 12-23% DNA rate for new cases. improving your experience’ leaflet which was seen in a • The total outpatient activity follow up rate is 499-738 variety of languages. This leaflet details the patient patients each month. advocacy and liaison service (PALS). However the ‘How • The service was achieving 73% of patients being seen to make a complaint’ leaflet was seen across the service within 18 weeks of referral for treatment. 7% of patients but only in English. On the last page of the leaflet it does breached over 18 weeks since Jun 2015. refer to three alternative translation options: large print, audio or Braille Meeting people’s individual needs • Posters and leaflets were displayed across the area • The service had access to a 24-hour translation service informing parents how to make a complaint. through “language line” and in-house interpreters. Staff • Any complaints received were displayed on the ward were aware how to access this service when required. safety board, which was situated at the end of the ward • Child and adolescent mental health services (CAMHS) on Princess Amelia and at the entrance of the Charlie were available through the local mental health trust. We Chaplin ward and showed no complaints for this year. were informed that this service would respond to the The board also included a ‘you said, we did’, which needs of the child and worked well. demonstrated how the staff listen to the feedback from • There was specialist support for caring for children with the Friends and Family Test or complaints. complex which includes diabetes, asthma and epilepsy. • The service had received no complaints over the past There was an identified Clinical Nurse Specialist for twelve months but had received five written learning disabilities and staff were aware how to access compliments. additional resources e.g. loop system or audio books. • We found posters across the service in English but none Are services for children and young in other languages although leaflets were available in several languages. people well-led? • There was a schoolroom available on level 10 with a variety of diversional therapy as well as schooling Good ––– support • The play specialist supported staff working with the The services for children and young people we rated team to support children and young people. as good for well-led. • Within Charlie Chaplin ward area, there was a secure We saw areas supported by good local leadership. outdoor play area and a conservatory room for children Governance arrangements were developed and to play indoors. performance monitored. We saw some escalation of • There was an area for adolescents within the ward, assurance and concerns from ward to the board level. which would meet the needs of the individual with game consoles and a television A children and young people’s risk register was in use and monitored at the monthly clinical governance meetings.

98 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

Communication and multidisciplinary working between Incidents were reviewed weekly to improve safety, medical and nursing staff was effective. reduce risk and ensure lessons were learned. Lessons learned were not seen on the incident list provided by The children’s senior staff communicated well with staff the trust. across the hospital and attended site operational • There was evidence of incident reporting and audit, with meetings. Children’s experiences were seen as the main identified themes and trends. priority. • Risk and governance folders were reviewed on the ward. However, we found no current Control of Substance This meant staff could access the latest information Hazardous to Health (COSHH) assessments that followed about clinical incidents. the trust wide process. • The service used a quality dashboard that was reviewed monthly at this service’s governance meeting, which Vision and strategy for this service escalated any concerns to the trust wide governance • The trust had developed a strategy, which focused on committee. quality improvements across the integrated healthcare • The children’s directorate risk register and meeting setting. Four of the eight staff inspectors spoke with told minutes were reviewed by us and was found to identify us they were aware of the local strategy for the risks related to: clinical quality of care, governance, directorate but not the trust wide strategy. estates, workforce, strategic change and finance. Risks • The philosophy of the service was to provide safe, high were scored from initial rating to a target rating and the quality patient centred care for children and young current rating. A colour code was applied to indicate people through integrated care across community and level of risk, using green, amber up to a red risk rating. acute settings. • Staff training, including risk awareness was evidenced • The trust merger had provided an opportunity for through the education and learning management children and young people’s services to be reconfigured. database(ELMS). There was evidence of integrated working between staff • Inspectors saw that not all parts of this service but evidence that policies and information technology governance worked effectively. Senior staff were not (I.T.) systems still remained separate between the two aware of trust wide changes for Control of Substance sites. Hazardous to Health (COSHH). The COSHH assessments • There had been recent changes within the hospital, with were checked by inspectors and were significantly out of six staff members expressing concerns about an date. Senior staff confirmed that all registers for this unsettled future with uncertainty also around dates service would be reviewed. when any changes might occur. • A “Risk news” information newsletter provided staff with • Senior nursing staff working in specific roles, such as feedback and shared lessons learned across the trust. clinical specialist nurses were aware of the vision and • We asked for but were not provided with the numbers of strategy for their own specialisms. staff that had completed root cause analysis training. • There was inconsistency of staff awareness of the trust Leadership of service values. • The majority of staff reported being well supported and Governance, risk management and quality told us senior staff would listen and respond when they measurement raised issues or concerns but that they were concerned • There were daily handover and ward meetings as well as about their future. safeguarding meetings. Clinical governance issues for • Eight staff told us that the senior team was assurance and escalation were then reported into the approachable. However staff reported that managers monthly directorate clinical governance meeting. Ward were not as visible since the trust as most managers meetings were held monthly around patient activity and were now based at Northwick Park.r we saw minutes from the last meeting. • The clinical directorate leadership was widely supported • A children and young people’s risk register was in use by all staff interviewed. and monitored at the monthly clinical governance Culture within the service meetings. These risks were escalated to the trust board.

99 Ealing Hospital Quality Report 21/06/2016 Ser vic es f or childr en and young people

Services for children and young people

• Staff described the service’s culture as being open and • One student nurse stated that they wanted to work at supportive but identified gaps in the integrated this trust when they completed their studies and were healthcare service. qualified, due to the support received whilst on • Staff stated they would be able to raise concerns placement. without fear of reprisal although one staff raised • The “Our Trust” magazine issue three for winter 2015 concerns about the approachability of her line manager. celebrated staff successes and the integrated trust first • Staff were willing to speak openly and they informed the anniversary. inspectors that their managers listened to them when Innovation, improvement and sustainability they raised concerns. • We saw multidisciplinary working with frequent • Development of the rapid access clinic, which is a meetings to support staff and sustain high quality general practitioners (GPs) paediatric, support service. patient centred care. This improvement in service provides crisis care for • The junior doctors we spoke to confirmed that children across the community. Children referred by consultants were supportive and described a structured their GP are given a same day or next day appointment training programme. and prevent accident and emergency attendance. • The play specialist supported children and young Public and staff engagement people to create drawings, clay models and poster • Patients and their families were encouraged to engage displays across Princess Amelia, which describes the with the service. background of this local historical figure, whom the • Friends and Family Tests were used and results ward was named after indicated that 95% of children and parents would • Senior staff discussed the innovation of the Ealing recommend this service. Services for Children with Additional Needs (ESCAN) - • Children were encouraged to share their experience multi-agency hub of services. through the sessions with the play specialist. • We were informed that ‘Schwartz’ rounds commenced • Staff were encouraged to develop professionally and in the trust eight months ago senior staff had attended one healthcare assistant informed us of her career but no evidence of paediatric cases discussed. Schwartz progression to nurse training. This was supported by her rounds are meetings which provide an opportunity for line manager and the trust. staff from all disciplines across the organisation to • We spoke to eight staff who reported positively on the reflect on the emotional aspects of their work. Senior level of engagement with their manager. staff informed us of the trust introducing the Schwartz • Overseas nurses were supported to develop at this trust. rounds with representation from this service. The trust was working with a local university to support • We were informed of the use of "optiflow" ( High flow overseas nurses with additional qualifications so that nasal cannula therapy for adults adolescents and they progress in their careers. children more than 8 years) to support HDU cases on the non-HDU ward.

100 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

Safe Good –––

Effective Requires improvement –––

Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

did not have complex serious illness or potentially Information about the service complicated deaths were supported by other generalist or speciality doctors and nurses on the ward the patient was End of life care (EOLC) refers to patients who have been admitted to; the SPCT was available to give support and identified as having entered the last 12 months of their life guidance to staff about these patients if they required it. or less. It refers to health care, not only of patients in the During the period 4 January to 29 September 2015 there final hours or days of their lives, but more broadly the care were 356 patients referred to the SPCT of which 53% had a of all those with a terminal illness or terminal disease cancer diagnosis and 47% had a non-cancer diagnosis. The condition that has become advanced, progressive and team on average received 500 referrals per year. incurable The hospital does not have any dedicated bed for patients Palliative care is a multidisciplinary approach to who are approaching the end of their life. Patients were specialised medical care for people with serious illnesses. It cared for in a side room on the main wards where possible. focuses on providing patients with relief from the The SPCT worked closely with the patient and those close symptoms, pain, physical stress and mental stress of a to them; the hospital doctors, ward nurses and other serious illness, whatever the diagnosis is (therefore cancer professionals in supporting the patient’s needs. They also or non-cancer). The goal is to improve quality of life for liaised with hospices and other community support both the patient and the family. Palliative care can be agencies. provided along with curative and non-curative treatment and is appropriate at any age and at any stage in a serious The SPCT was available Monday to Friday from 8am to 4pm illness. and out of hours on-call cover was available to clinicians. Palliative care is provided by a specially-trained team of We spoke with 12 members of staff; which included local doctors, nurses and other specialists who work together level service leads for specialist palliative care and end of with a patient’s other doctors to provide an extra layer of life care, ward nurses, allied health professionals, clinical support. It is appropriate at any age and at any stage in a nurse specialists in palliative care and consultants, serious illness and can be provided along with curative administration staff, porters, staff in the bereavement office treatment. and mortuary and a chaplain. The specialist palliative care team (SPCT) for Ealing We observed staff interactions with patients and those Hospital is made up of two clinical nurse specialist (CNS) close to them and spoke with two patients and two and consultant support based at Meadow House Hospice, relatives. We reviewed five care records and eight do not which is located on site at Ealing Hospital. The SPCT provided specialist support for people facing serious illness which was usually complex. Patients who

101 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care attempt cardio pulmonary resuscitation (DNACPR) records. We also reviewed thank you cards and letters. During and Summary of findings prior to the inspection we requested a large amount of data in relation to the service which we also reviewed. We rated the end of life care services at Ealing Hospital as ‘requiring improvement’ overall. We found the specialist palliative care team (SPCT) to be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner. They were hard working and supported the ward-based teams on a daily basis. We saw that staff considered cultural differences when discussing death and dying and only took the conversations as far as the family were comfortable. However, less experienced staff could use this as a reason not to discuss a patient’s prognosis which meant some patients and families may not know what resources are available to them at the end of life. The mortuary and bereavement staff were aware that different cultures had different needs when caring for patients and families after death. The patients and relatives spoke positively about their interactions with the teams involved in their care. They described the staff as “considerate and thoughtful” and "caring and kind". They told us they were understood and able to raise any concerns they had. One compliment letter said “the doctor's sensitivity and with high integrity educated us to the gravity of our relative's condition.” The trust had responded to the withdrawal of the Liverpool Care Pathway, which had previously been seen as best practice when someone reached the last days and hours of life. The trust used a holistic document which was in line with the five priorities of care. This care plan, called the ‘Last Days of Life Care Agreement' (LDLCA), guided staff to consider and discuss the patient’s physical, emotional, spiritual, psychological and social needs. The LDLCA also took into account the views of those important to the patient and provided them with an information leaflet about what happens when someone is dying, and what to expect. As part of the LDLCA, the patient’s pain relief, symptom management and nutrition and hydration needs were monitored and recorded at regular intervals during the day. Patients’ records and care plans were regularly

102 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

updated; matched the needs of the patient, and were they were still the key driver for improving staff relevant to EOLC. The LDLCA reminded staff that they engagement, training and skills. The SPCT at Ealing should remain open to the possibility of changing the hospital did not feel engaged with the trust strategy and plan should a patient’s clinical condition change. This were unsure how it would affect services at Ealing included withdrawing the LDLCA if the patients did not Hospital. While they were listened to by the service leads deteriorate at the expected rate and it was no longer they did not feel they were unsure of their influence appropriate for it to be used. The LDLCA was not being trust wide. used for any of the patients we reviewed, although ‘do not attempt cardio pulmonary resuscitation’ orders were in place. The completion of DNACPRs was variable. Some were not fully completed or discussed or signed off by a senior clinician. The SPCT leads were focussed on raising staff awareness around EOLC. However they said that this should be a trust wide responsibility as “death and dying is everyone’s business” and the onus should not be placed solely on the SPCT to take forward. The trust had recently secured funding to develop an e-learning package for all staff to complete. There were some concerns raised by specialist staff about whether all generalist nurses, doctors and consultants had the expertise to recognise patients who were dying; and had the skills to have difficult conversations about planning care for those at the end of their life. Staff were aware of their responsibility in raising concerns and reporting incidents. However, we found there was apathy in reporting everything including near misses due to a lack of feedback and learning outcomes. Staff were able to explain their understanding of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). They told us they would act in the best interests of the patient should they lack mental capacity to make decisions for themselves. They understood that a patient’s carer should be consulted in gaining an understanding of what the patient would want when making best interest decisions and people could not consent on behalf of the patient unless they had a relevant legal directive to do so. All staff understood their role and responsibility to raise any safeguarding concerns. The SPCT leads reported a better emphasis on EOLC at board level over the last year. However, they said that

103 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

supported training staff on the wards where any EOL or Are end of life care services safe? palliative care incident were identified. We were told that incidents relating to EOLC were shared across the hospitals Good ––– in the trust. There were good arrangements in place to manage Safety across Ealing Hospital for end of life care was good. patients’ medication in the hospital and for patients to take All staff received mandatory training and the SPCT had home with them if they were discharged. Syringe drivers achieved 100% compliance in most subjects. Safeguarding were available for appropriate patients and there were no vulnerable adults, children and young people was given reported difficulties in getting them. sufficient priority. Staff were able to communicate their responsibility and role in early identification of any Safety performance, Incident reporting, learning and concerns. They know whom the safeguarding lead for the improvement trust was and where to get guidance should they require it. • Serious incidents known as ‘Never Events’ are largely The SPCT were highly skilled in supporting patients with preventable patient safety incidents that should not complex health issues and requiring palliative or EOL occur if the available preventative measures had been support. Patients who came under their care were regularly implemented. End of life care (EoLC) services had not assessed and any changes documented clearly. However reported any never events or serious incidents in the we had some concerns about whether generalist nurses, last 12 months. and some doctors and consultants always recognised a • The trust had systems in place to report and record change or deterioration in a patient that could indicate safety incidents, near misses and allegations of abuse; they were approaching the last 12 months or less of life. and share any learning and changes to improve the This meant that a patient identified as requiring EOLC safety and quality of the service. In the period form 1 could continue to receive treatment and observations that July 2014 to 31 July 2015, the trust reported no incidents were no longer beneficial and could cause unnecessary relating to the palliative and end of life services across discomfort for the patient. the hospital. However there were incidents which related to patients who were in the end of life phase or Where staff used the ‘Last Days of Life Care Agreement’ receiving palliative care. The a majority of these were (LDLCA) document to plan holistic care and support for the relating to the community services. There were two dying patient, the record was clear. Staff spoke positively reported incidents relating to the mortuary; one relating about this record as it guided them through everything to the bariatric fridge being out of service, and the other they should consider and discuss with the patient and related to a deceased patient who was not identified by those close to them. However this document was not ward staff as having an infectious disease. The incidents compulsory to use and where it was not used we found were adequately investigated with all parties involved in that records were difficult to navigate. Conversations and the incident from acute and community services. A root agreed treatment and care options were scattered cause analysis was completed with learning points throughout the patient’s record and did not give a clear identified. picture without reading back through notes. • Staff told us they used the electronic reporting system Openness and transparency about safety was encouraged. ‘Datix’ to report any incidents of concern. The SPCNs Staff fully understood their responsibility to raise their told us they tried to raise any concerns with the ward concerns and report incident and near misses. However, we manager or sister at the time of it being identified.They found apathy amongst some staff to report all incidents received confirmation that any reported incident had and near misses due to a perceived lack of feedback and been received by their manager but told us they rarely learning outcomes. Those incidents that were reported received feedback on the outcome or any related were investigated adequately and learning points and learning. The SPCNs said that reporting incidents and actions identified in the incident reports. The SPCT near misses had declined due to the lack of feedback and learning.

104 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• The Datix system allowed incident reports to be shared collected the body. However the nature of the infection between Ealing and Northwick Park Hospitals. There was not disclosed unless necessary. Personal protective were opportunities at joint meetings to discuss equipment such as gloves or aprons were provided to incidents that affected all services across the trust, for undertakers if required. example those that meant a change in policy or Environment and equipment procedure. Reminders were displayed on the trust’s computer screen savers. • The trust used T34 syringe drivers, which were all of a • Staff were trained on duty of candour as part of the risk standardised type that conformed to national safety management training at induction and the mandatory guidelines on the use of continuous subcutaneous update training. The staff we spoke with understood infusions of analgesia. their role and responsibility in informing patients of • Each ward was encouraged to take responsibility of incidents that could or have affected them. They told us getting and returning syringe drivers to the store at the they would apologies, explain what actions have been hospital. Any issues in relation to the use of care of taken as a result of the situation and offer support. Staff syringe drivers was reported on Datix. added they would support a patient in making a formal • The trust had responsibility for maintaining all the complaint if they were not satisfied with actions taken. syringe drivers. We were told there were no problems in We saw apologies made to patients and carers was accessing syringe drivers whenever they were needed documented in patient records and on Datix. for patients. • The mortuary manager had put in place many Cleanliness, infection control and hygiene processes to ensure that the deceased was kept in the • We found the trust had systems in place to prevent and best condition as possible. Fridge temperatures were protect people from healthcare associated infections. checked daily and any concerns reported immediately. The trust had an infection prevention and control policy Systems were in place to ensure the correct identity of (IPC) and all staff received training. The staff we spoke the deceased person including measures for patients with had a good understanding of IPC practices and we with similar names. We observed a tight checking observed staff following IPC measures when visiting the system when undertakers came to transfer a body. patients on the wards. Staff were aware of patients’ • All the equipment such as trolleys, cleaning equipment reduced immune systems and the measure they should and personal protective equipment was clean and take in order not to compromise their health through stored in a tidy manner. No post mortems took place at poor infection control. the hospital. There was a male and female changing • Infection prevention and control formed one of the room available for the mortuary technician. mandatory training modules for staff. The SPCNs had • A viewing room provided families or friends a private completed this training. quiet space should they wish to spend time with the • The mortuary area was spotless, tidy, smelt fresh, and deceased. We found this and the waiting area was clean clean. We observed strict hand hygiene measures and and tidy. Deceased children and babies were laid out in visitors to the mortuary area were reminded of the a smaller bed or a Moses basket. importance of cleansing their hands prior to leaving the Medicines management premises. • Deceased patients who had an infectious disease were • There were arrangements in place to keep people safe identified by a wristband and placed in a body bag. A and manage medicines for patients. Medicine high-risk identification sticker was attached to the bag management formed one of the mandatory training once they arrived at the mortuary, where they were modules for staff. Training records showed that one of placed in a separate fridge. Any visitors for the deceased the SPCN’s medicine management training had expired. were advised not to touch the body and the undertakers We were unable to tell if the other SPCN had completed were informed for their own protection when they their training, as the record we received from the trust was incomplete.

105 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• As part of the patients’ holistic assessment, symptom including ambulance and community services. This control and medication was monitored and reviewed by means the patient receives the most appropriate care a SPCN and any changes were discussed with the and treatment and prevents unnecessary hospital consultant responsible for their care and the ward staff. admissions. This was documented in the patient record. Safeguarding • Patients who expressed a wish to die at home were discharged from the acute hospital with anticipatory • Staff understood their role with regard to keeping injectable medication and medication record charts. patients’ safe and reporting any issues. This included These were provided to patients whose condition may identifying any risks to the patient’s family such as require the use of injectable medication to control children or vulnerable adults whose main carer may be unpleasant symptoms if they were unable to take oral the patient. medication due to their deteriorating condition. Having • All staff complete training about safeguarding children anticipatory drugs available in the home allowed and vulnerable adults as part of their mandatory qualified staff to attend and administer drugs, which training modules. Staff we spoke with demonstrated an may stabilise a patient or reduce pain and anxiety and awareness of safeguarding procedures and how to prevent the need for an emergency admission to recognise if someone was at risk or had been exposed hospital. to abuse. Staff told us if they had any concerns they • Where appropriate patients had syringe drivers which would speak to the trust safeguarding lead or their delivered measured doses of drugs over 24 hours. They manager, and knew where to access the trust policy on could be discharged from hospital with a syringe driver the intranet. in place however this needed to be changed to a syringe • Staff safeguarding level 1 and 2 training for adults was driver from the community resources as soon as part of mandatory training and was routinely provided practicable and the hospital driver returned. to all staff. Similarly safeguarding children level 1 • The syringe drivers were locked as per guidelines to training was provided to nearly all staff including prevent other people altering or increasing doses. administrative and clerical staff. Safeguarding children • We noted that medication administration records were level 2 was mandatory for all nurses and allied health completed correctly and signed. We found the professionals. The SPCT had achieved 100% compliance prescribers’ names were not always clearly printed on in safeguarding children level one and two; and 100% the medication administration records although they compliance in safeguarding adults’ level 2. were always signed, this could make it hard to find the Mandatory training prescriber if anyone needed to discuss the prescribed drugs. • All staff took part in mandatory and statutory training to • There was not specialist palliative pharmacy ensure they were trained in safety systems, process and support available for staff. However they could get practices such as basic life support, conflict resolution, advice and support from the hospital’s pharmacist. fire safety, infection control and health and safety. • Many of the mandatory training modules were accessed Quality of records thought the trust’s online training system called ELMS. • People’s individual records were written and managed Staff reported positively about this system as they could in a way that kept them safe. Records reviewed were track their own training and received reminders when it accurate, legible, and up to date and stored securely. was due for renewal. Their manager also received • Patients’ palliative care needs, care plan and reminders so that they could ensure all their team had resuscitation status was entered onto a system called completed their training. Many of the training modules ‘Coordinate my Care’ (CmC). CmC is a shared clinical were through online teaching sessions. However some service which allows healthcare professionals to record modules such as basic life support were still completed a patient’s wishes and ensures their personalised care in a practical face-to-face session. plan is available for all those who care for them, • All staff from the SPCT told us they had completed their mandatory training or were due to complete it in the

106 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

next few weeks. Records showed the SPCT had reached Nursing staffing 100% compliance in 13 out of 15 subjects. One member • National commissioning guidance suggests the of staff was no longer compliant in medicines minimum requirement for specialist palliative care management and diabetes management in hospital. nurses (SPCN) is one SPCN per 250 beds. Ealing Hospital • The mortuary staff and porters received mandatory has approximately 358 beds. The SPCT was made up of training. Mortuary staff were 100% compliant. The two whole time equivalent (WTE) band 7 clinical nurse porters had not achieved the trust’s compliance level of specialists (CNS). 80% in some subjects. The training matrix for • The trust’s lead nurse for cancer and palliative care September 2015 showed 71% compliance in infection visited the Ealing team twice per week. They line prevention and control, 60% in safeguarding and 62% in managed 24.7WTE staff (this included the Macmillan manual handling. clinical nursing specialists).Funding for a matron post to Assessing and responding to patient risk concentrate purely on palliative and EOLC across the trust had recently been applied for. • We found that patients supported by the SPCNs were regularly assessed and any changes in the patient were Medical staffing identified quickly. Care plans were updated and • Commissioning guidance suggests the minimum discussed with the nursing team caring for the patient requirement for consultants in palliative medicine is one day-to-day. WTE per 250 beds. One consultant based at Meadow • We found a mixed response in how well the nurses on House Hospice (MHH) which was based in the hospital’s the wards recognised a patient was approaching the last ground provided one session per week at the hospital. 12 months or less of life. Some of the SPCNs had They and the other consultants at MHH were reported to concerns whether generalist nurses always had the be flexible and would come to the hospital at any time if experience to recognise a patient who was deteriorating required. However, the arranged consultant cover did and reaching the end of their life. They told us they did not appear to be sufficient according to not think that staff knew the difference between commissioning guidance. specialist palliative care and EOLC. This varied recognition could mean some patients would not receive appropriate support and in the way they would Are end of life care services effective? like it, as there was a lost opportunity to discuss advanced care plans in the last 12 months or less of Requires improvement ––– their life. • Most of the staff we spoke with in on the wards were We rated effectiveness of end of life care as requires aware they could access advice and request specialist improvement. support from the SPCT if their patient had been identified as requiring palliative or EOL support. There were concerns some ward nurses and doctors lacked However the SPCNs were concerned that they would the expertise or experience to recognise when a patient not request the support if they did not have the was in the last 12 months or less of their life; or was rapidly necessary skills to recognise that a patient had deteriorating due to being at end of life, especially if they deteriorated in the first place. were frail and elderly. • At the end of life, there are inevitable changes to the We found that staff did not always complete ‘do not body such as weight and skin integrity. Staff used tools attempt cardio pulmonary resuscitation orders’ (DNACPR) to assess risks to patients, such as a pressure damage in line with best practice and national guidance. The trust risk assessment to identify and prevent pressure ulcers. audited the DNACPRs and had an action plan in place to We saw the assessments were completed fully on the improve their completion. trust’s electronic patient record system. Appropriate pressure relief mattresses and advice on how to reduce End of life care was managed in accordance with national the risk of pressure trauma and maintain healthy skin guidelines. was provided to patients assessed at risk.

107 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

The SPCT (specialist palliative care team) was made up of a and bereavement services and did not given any advice highly skilled and knowledgeable staff group who or links to EOLC. We pointed this out to the senior SPCT supported patients with palliative care and end of life staff and they said they would take this up with the team patients with complex health needs. The CNSs provided as it was a lost opportunity to promote the difference effective support and advice to staff supporting patients between palliative and EOLC. with palliative or end of life needs. • End of life care was managed in accordance with national guidelines. The LDLCA document guided The trust had responded to the phasing out of the clinicians through a series of prompts to discuss with ‘Liverpool Care Pathway’ with a holistic care plan called the the patient and those close to them. This assessed the ‘Last Days of Life Care Agreement’ (LDLCA). This document patient’s personal and clinical needs, their preferences was not compulsory to use although all staff were expected and wishes, and the amount of intervention they to consider the five priorities of care which took into wanted. It gave clinicians support in explaining why account a patient’s wishes, and emotional, psychological some clinical interventions may not be appropriate and and spiritual needs. We saw the LDLCA was fully completed what happens when someone is dying. The care plan for those patients who had one; the plan of care and was holistic, shared with colleagues and delivered in reasons behind the decisions was clearly documented. line with best practice. This document was not Ealing Hospital’s SPCT had in the past provided EOLC and compulsory to use. However clinicians were expected to palliative care training at induction. However this had been consider documenting a holistic care plan and the discontinued since the merger of the hospitals and had outcome of the discussion in the patient’s records. created a gap in staff’s knowledge. The trust had identified • The EOLC documents used achieved the ‘Priorities of the need for all staff to complete a training module in end Care for the Dying Person’ as set out by the Leadership of life care and recognising dying. The trust had recently Alliance 2014 for the Care of Dying People. Records approved funding to develop an e-learning package for all reviewed showed open communication with the patient staff to complete. and family, recognition of dying, symptom control, and assessment of nutrition and hydration needs; and Ealing Hospital routinely collected and monitored guided clinicians to discuss the patient’s wishes and information against key performance indicators to measure those involved in the patient’s care and consider their the outcome of people’s care and treatment. The hospital emotional, psychological and spiritual support they took part in national and a minimal number of local audits. may need. The service level leads expressed the need to collect more • Records reviewed met with the draft National Institute complex information to understand patient outcomes and for Health and Care Excellence (NICE) guidelines 2015 improve on services across the whole trust. for EOLC for review and the Leadership Alliance 2014 five Evidence-based care and treatment priorities for continual review of symptoms and discussion/communication with the patient and people • The trust’s response to the independent review of the important to them. We observed a written evaluation of use of the Liverpool Care Pathway (LCP) for the dying care, and discussions and reviews carried out were patient and the subsequent announcement of the completed in the patient’s records three times a day by phasing out of the LCP was to create a document call a doctor as well as the symptom checklist being ‘Last Days of Life Care Agreement’ (LDLCA). This was completed by the nurse six times a day. available on the trust’s intranet with supporting • We saw that the trust’s ‘integrated care pathway (ICP) for documents such as information for relatives and carers the rapid (or complex) discharge home of the dying about when someone is dying. We observed ward staff patient indicated that it was based on the ‘Beacon being shown by a SPCN where to find the documents Awarded Liverpool Hospitals Integrated Pathway for the and how to use them. Staff who used the LDLCA spoke care of the dying patient’. Practitioners were advised positively of it as it gave them a clear plan of care agreed that they could exercise their own professional by all those involved. judgement and any alterations to the ICP must be noted • We saw that when staff searched for EOLC on the trust’s intranet it directed them to a page about Chaplaincy

108 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

as a variance. Referring to the LCP could cause patients interests. It is unclear whether giving parenteral fluids to and families concern that they are on the ‘pathway to people who are dying causes, rather than alleviates, death’ due to the adverse attention the LCP received symptoms therefore every case was considered on an culminating in its eventual phasing out. individual basis and the reasons to administer or not was explained to the patient and family. Pain relief Patient outcomes • We found anticipatory prescribing followed the new draft NICE guidelines for symptom control. Some pain • Ealing Hospital routinely collected and monitored control was managed with PRN (‘pro re nata’ / as information about the outcome of people’s care and required) paracetemol. Patients told us they had treatment. The key performance indicators (KPIs) received pain relief and their pain was dealt with included how many patients had a preferred place of effectively. death; recorded the number who achieved their • The SPCT’s consultants and nurses were experts in their preferred place and ethnicity. Measuring outcomes field and able to provide guidance on the most effective allowed the team to monitor their targets and drive up and appropriate treatments and care at end of life, improvement if required. which included pain relief, nausea and vomiting. • The trust participated in the National Care of the Dying • Where appropriate patients had syringe drivers which Audit – Hospitals (NCDAH). The audit was made up of an delivered measured doses of drugs over 24 hours. All organisational assessment and a clinical audit. Ealing qualified nursing staff were trained in using syringe hospital had achieved four out of seven key drivers and symptom management. performance indicators (KPI) in the organisational audit • The CNSs were not trained as prescribers. However they and three out of ten KPIs for the clinical audit. Clinical told us the doctors were usually good at taking their audit revealed gaps in the following KPIs: advice regarding symptom control and pain ▪ MDT recognition of dying management and prescribed in a timely manner. Each ▪ Discussions with patients and families in preparation ward had a pharmacist and they could dispense the for death drugs quickly. ▪ Communication of plans to patients and families ▪ Assessments of patient and family spiritual needs Nutrition and hydration ▪ Discussions regarding provision of nutrition and • Nutrition and hydration needs were identified in the hydration during the dying phase patient’s care plan as part of the ‘LDLCA. Prompts for ▪ Medication prescription for the 5 key symptoms of staff to follow when explaining nutrition and hydration dying were included in the agreement and there was space to ▪ Regular review of the patient during the dying write what was discussed and the patient and families' process response to the discussion. The SPCT had analysed the main findings of the audit and • Staff assessed each patient and support and guidance had proposed a number of recommendations to improve was provided on an individual basis. Input at EOL was the services, such as improving recognition of approaching around supporting the family when a patient stopped death. The action plan clearly outlined the eating and drinking due to entering the dying phase. recommendation, progress and completion dates. The SPCT was also involved in the MDT meetings and supported patients and families in the decision making • The hospital had submitted data for the most recent process of when to reduce enteral feeding. NCDAH and the results were due in May 2016 this would • Patient’s oral fluid and food intake was encouraged as show whether improvements had been made since the long as the patient was able to swallow and wanted to last audit. eat and drink. Hydration and nutrition needs were • The hospital provided data to Public Health England’s monitored and reviewed with the patient and people ‘Minimum Data Sets (MDS) for Palliative Care’. The aim of important to them and nurses acted on any concerns. the MDS is to provide good quality, comprehensive data • Subcutaneous fluids (artificial hydration) were about hospice and specialist palliative care services on considered if it was seen to be in the patient’s best a continuing basis. The data is useful for service

109 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

management, monitoring and audit, development of • The SPCT provided support and training at the bedside strategy and service planning, commissioning of to generalist staff. The CNSs visited each ward in the services and development of national policy. The trust hospital every day to identify any help the staff and had very recently received the results for 2014/15, and patients may need. they were currently reviewing how they performed • Generalist and specialist nurses and doctors who against other organisations of a similar size to them at a regularly supported patients at the EOL could take a national and local level. secondment opportunity at Meadow House Hospice in • The trust took part in the ‘London Cancer Alliance order to gain further confidence and expertise in Palliative Care Audit’. This showed how the hospitals supporting patients who had life limiting illnesses or and hospice performed against other providers across were at the end of their life. London. The comparison of numbers of individuals seen • Sage and Thyme ® communication training was by Ealing Hospital had seen a small decrease from 445 available to all staff in the trust, including administrative in 2011-2012, to 431 in 2013-2014. The average across staff. This training was designed to train all grades of London was an increase of 6.1%. staff in how to listen and respond to patients/clients or • The hospital took part in the bereavement audit (this is carers who are distressed or concerned. Staff who had an optional part of the NCDAH). They were in line or undertaken this training spoke positively about it as better than the results from National Survey of Bereaved they were more confident in having a conversation with People (VOICES) 2014. someone who was distressed or concerned. Competent staff • The palliative medicine consultants and SPCNs took advanced communications skills training so that they • The SPCTs were made up of competent and highly could support patients and families through difficult trained individuals. A majority of staff reported having conversations and breaking bad news. Both of the CNSs the opportunity to develop and attend further had completed this training. education courses in line with their role. Although at • Porters were employed by a private company who times workload meant they were unable to attend as trained them in EOLC for the deceased. This included many courses or conferences as they would like to. treating the body with dignity and respect, how to • Staff had regular one to one meetings and clinical transfer bodies from the ward to mortuary, and supervision where they could discuss concerns and any mortuary procedures. cases they had found emotionally difficult. • Prior to the trust merger with Northwick Park and Multidisciplinary working Central Middlesex Hospital’s the team had run regular • Each of the CNSs held their own caseload of patients. EOLC and palliative care induction training for all staff. However the two team members spoke every day and However since the merger it had been stopped and the had a more formal discussion each week about their CNSs expressed a concern that recognition of the dying patients. patient was patchy. They also said that junior staff did • A member of the SPCT aimed to attend ward not know the difference between EOL and palliative care multidisciplinary team (MDT) meetings, especially on and the support the SPCT could give. wards where patients were likely to be identified as • There was some concern that doctors did not always requiring palliative or EOLC. We observed on MDT which have the skills or expertise to recognise when a patient was made up of a first year doctor, psychiatrist, social was not going to recover from their illness or in the last worker, discharge lead, dietician, ward manager, 12 months of life or less, and therefore did not consider physiotherapist, occupational therapist and CNS. The discussing advanced care planning. The lack of multi-professional team identified extra support the recognition could also lead a patient to receive patient required, such as clinical expertise or social or treatment and undertake observations that was no psychological support. We observed the team assess longer beneficial to them. and plan on-going care, which included moves between teams or services such as discharge to a community or home setting.

110 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• The team discussed care plans, which were should deliver to the patient. The trust audited the individualised and based on the patient’s wishes and number of patients entered onto CmC and 100% of needs. We witnessed staff of all levels were clear and those eligible to be on CmC had been included for the open challenge between each other, relevant questions period between April and October 2015. were asked to draw conclusions. Consent, Mental Capacity Act and Deprivation of • There were clear pathways between the hospital and Liberty Safeguards community settings to facilitate patients being discharged (if safe to do so) to home, hospice or care/ • Staff undertook Mental Capacity Act (MCA) 2005 and nursing home. Deprivation of Liberty Safeguards (DoLS) training as part of their mandatory equality diversity and human rights Seven-day services training. We gave hypothetical situations to staff and • The SPCT provided face-to-face support from 8am to most of them were able to describe the process they 4pm Monday to Friday. would follow should someone be found to not have • MHH provided a 24-hour helpline for clinicians. They consent to agree to treatment or be able to make triaged the calls and directed the caller to the most decisions in relation to their care. This included appropriate support, such as the on-call CNS or consulting with people who were close to them to consultant. gauge what the patient would have wanted in order to • The mortuary was open form 8am to 4pm Monday to make best interest decisions. Friday. Porters accessed the mortuary area outside of • MCA and DoLS guidance was available of the trust’s these hours and the mortuary manager or a regular intranet and associated documents such as the consent locum was available on-call if there were any issues. policy, dementia policy and safeguarding adults at risk policy. Access to information • The policy for consent to examination or treatment was • During September and October 2015, the trust had available to staff on the trust’s intranet.This was under migrated patient electronic records from one electronic review at the time of our inspection. We found it made patient record system to another, with an aim for more reference to the Mental Capacity Act (2005). A mental accessibility and improved information sharing capacity assessment checklist and a consent training opportunities across the trust. competency proforma were included in the policy. • Information about each patient the CNSs were • Staff could access support and advice from the hospital supporting was held in a card box file, which both of social workers in relation to the MCA and DoLS. We them had access to. If there was unexpected staff spoke with one DoLS assessor who had come to the absence SPCT team members from Northwich Park hospital to assess two patients at EOL, as they appeared could access this information in their CNSs office at to be lacking the mental capacity to consent or make Ealing Hospital. They were not able to access any decisions. The assessor told us all applications were electronic records remotely should they need to assessed and then agreed by a mental health doctor. give telephone support. However staff from MMH could • We reviewed ten do not attempt cardio pulmonary visit patients in the hospital in urgent cases. resuscitation (DNACPR) forms. We found six to be • Patients who were identified as at end of life and had an completed correctly. The level of completion for the advanced care plan and/or a do not attempt cardio remaining four was variable. For example, two forms pulmonary resuscitation (DNACPR) were entered onto had not been completed or signed by a clinician with an electronic record called ‘Coordinate My Care’. The sufficient seniority. Another patient had two DNACPR patient’s illness, wishes and personalised urgent care orders which created a confusing picture; and another plan could be accessed by anyone involved in the their detailed that the decision for DNACPR was in the care, such as their GP, community nurses, hospital team, patient’s best interest due to age and dementia and did out-of-hours doctors, specialist nurses, and ambulance not otherwise identify the patient's illness or condition. service. This allowed them to know what care they • DNACPR forms completed in acute settings were not transferrable with the patient to their home, care/ nursing home or hospice therefore the patient’s GP was

111 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

responsible for completing a DNACPR directive as soon one patient. Other patients had been identified for us to as possible after the patient reached their home. This visit but we were advised not to visit one of them due to ensured all interested parties fully understood the their circumstances and the other three had died before we process. could meet with them or their relatives. The patient we • The trust-wide DNACPR audit report dated November spoke with told us although the staff on the ward “were 2015 looked at 155 DNACPR orders across the three very kind, and had time for you even though they were very hospital sites (Ealing [33 patients], Northwick Park [93 busy.” patients], and Central Middlesex [29 patients]). The audit Patients' privacy and dignity was maintained and we identified areas of good and poor practice. observed staff asking permission to enter a patient’s room ▪ The audit found that in 26 cases there was no or bed space if the curtains were closed. Patients were summary of communication documents with either addressed by their preferred named and a ward nurse was the patient or those close to them; 46 patients had identified each day as their main carer. Staff introduced capacity to make and communicate decisions about themselves, explained what they were doing and why, even CPR and 101 lacked capacity.There was no with patients who were not completely aware of their documentation for seven patients. surroundings or very conscious. ▪ 150 DNACPR forms had the date of the decision recorded and 114 forms had the time of the DNACPR We observed positive interactions between staff and recorded. patients. The porters described how they always “chatted ▪ 140 DNACPR forms had documented the grade of the with the patients and told them what they were doing”, doctor making the DNACPR decision, 105 of these they ensured they moved patients as quickly and gently as decisions were recorded by a registrar or above possible when transferring them from one location in the grade doctor, and four forms had been completed by hospital to another, such the ward to x-ray department. The a Senior House Office/FY1 doctor. described how they transferred deceased patients from ▪ Good practice included name, hospital/NHS number, the wards maintaining maximum privacy and dignity when address, DNACPR decision being recorded and the moving in public spaces. number of patients who had a capacity assessment. We heard at the MDT meeting that staff were able to give a The audit report made recommendations for improvement clear account of the patients’ circumstances and family/ such as documenting the reasons why CPR would be social background. There were a number of resources inappropriate, summary of communication with patient available for emotional support for patients and those and those close to them and a summary of main clinical close to them which included clinical staff, a multi-faith problems identified and documented. The immediate chaplaincy service and Macmillan cancer care services. actions taken included consultants completing the review We saw from patient records that discussions were held dates and documenting them, assessing patient’s capacity with patients and those close to them. However we noted and signing the orders; sharing the findings of the audit in some care records that the patients or relatives views with ward staff; and a request that DNACPR status is were not detailed fully, although it indicated the discussion reviewed by the medical multidisciplinary team. Further had taken place. Therefore, we were unable to ascertain analysis was planned to identify any trends and themes what was said and what the response was and any and the results were going to be RAG rated; this is a traffic concerns or questions raised by the patient or family light system (red, amber, green) to identify the level of risk. member. Are end of life care services caring? The mortuary manager had a caring approach and considered the needs of the deceased and those close to Good ––– them at all times. They aimed to fulfil family requests, such as dressing them in their own clothes, wherever possible.

The support and care given to patients identified as at the Compassionate care end of their life and after death was good. We spoke with

112 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• The results from the NCDAH local survey of bereaved mortuary manager was not on-duty. This information relatives were in line with the National Survey of included things that were important to the patient or Bereaved People (VOICES) 2014; 66% of people thought family, such as always having a pillow under their head the doctors and 70% of people thought the nurses or facts, such as the person being a previous member of always treated their relative with respect and dignity staff at the hospital, or a staff member’s relative. during the last two days of life. They scored 13 in the Understanding and involvement of patients and those friends and family test with 68% of people saying they close to them extremely likely or likely to recommend their friends of family to the hospital, while 12% were unlikely or • Patients were given a named nurse on the wards. This extremely unlikely. allowed patients and those close to them to identify • We visited the wards and saw staff treated patients and who was responsible for their care on a day-to-day their families with respect and worked hard at basis. The CNSs shared the patient caseload. Both team maintaining people’s dignity. Staff sought permission to members were aware of the patient should they need to enter the patients’ bed space prior to entry. We heard support them in their colleague's absence. staff introduce themselves to any patient they had not • We found the CNSs and most of the ward nurses had a seen them before or to remind a patient of who they good understanding of their patients and what was were. important to them. They spoke about their patients in a • We observed staff provide care and support. We noted personable and caring way. Those nurses that did not how they took great care to explain what they were know their patients well were generally newly qualified going to do and how they were going to do it, and and relied on their mentor’s knowledge. ensure that the patient, and family if appropriate, were • Records showed some discussions between clinicians happy for the care to be undertaken. and patients and those close to them. In some cases the • Patients and families told us they were very happy with views of the family were detailed, while others only the support they received from the nurses. One patient stated that the family member “agreed” with whatever told us “the staff have been very good, they sorted out had been discussed, such as DNACPR. my pain.” • One patient we spoke told us that, despite having had a • Porters and mortuary staff said that the bodies of conversation with the palliative care consultant on more deceased patients were handled in a compassionate than one occasion, they were still unaware of some of way and there had not been any concerns about the their symptoms. This was causing them major concern condition of the bodies when they arrived in the especially as they were going home and the symptom mortuary area. they had affected their life. • A deceased person’s possessions were kept by the Emotional support bereavement office in an individual bag. This was returned to family members when they collected the • The results from the NCDAH local survey of bereaved death certificate. This meant they did not need to make relatives indicated that 76% of people thought overall multiple trips to the hospital unnecessarily. that they were adequately supported during the last • The bereavement officer told us how they built up a two days of their relative’s life. rapid relationship with families to support them in an • The SPCNs, ward staff and chaplain gave emotional individualised way. They gave them the time they support to patients and their relatives. Staff told us they needed to discuss what happens next. would give them as much time as they needed to talk • We observed the mortuary manager consider each of about their thoughts and feelings. They told us of other the deceased in an individual way. For example one agencies which could offer support to the patient and family member was worried their relative would be cold those close to them, such as counselling services and and asked them to be dressed in their own warm spiritual/faith/religious leaders. clothes. We saw that this had been done. The mortuary staff had also created a ‘deceased patient passport’ where they documented conversations or social facts that were important for other staff to know if the

113 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• The hospitals’ multi-faith chaplaincy service was professionals had started to use it. We did not find it in use available to support patients and we saw evidence of in any of the patient records we looked at on the ward. This staff offering this service. Patients and families were able meant there could be potential gaps in the discussions to arrange for their own spiritual leader to visit the held by clinicians who may only take into account the hospital. patients clinical needs and not enter into other issues that • The bereavement officer supported relatives and friends could be important those involved in the patient’s care. after a patient’s death by explaining all the legal Hospital staff referred a majority of patients who had died processes and what to expect when someone has died. in the hospital to the SPCT, this included patients with An information pack which included contact details for cancer and non-cancer diagnosis. The SPCT regularly support and counselling groups was provided. received an average of 500 referrals per year and support • Emotional support extended to the clinical team from the CNSs was provided in a timely manner. through peer support and one to one clinical supervision. Staff told us they could take some time out Patients were supported in being transferred to their if they found it hard to cope at any point. However, this preferred place of death through a 24-hour rapid discharge was said to be rare as the day to day support they gave process. The hospital collected data on how many patients each other was usually enough. had their preferred place of death recorded and how many • An annual memorial service took place for people close achieved it, figures showed they achieved the set targets for to a patient who had died at the hospital. this. The reasons that a patient did not die in their preferred • Schwarz rounds were run for staff from all disciplines. place was recorded so any issues that did not meet an Schwarz rounds are designed for staff to discuss individual’s pretences could be identified. emotional and social issues that have arisen in caring The chaplaincy, mortuary and the bereavement office took for patients. This allowed staff to reflect and explore the into account people’s religious customs and beliefs and human and emotional aspects of the experience of were flexible around people’s needs. For example, some delivering care and the challenge they face from cultures required the release of the deceased’s body within day-to-day. 24 hours of death. There was suitable service provision at night and at weekends to accommodate this. There was a Are end of life care services responsive? multi-faith chaplaincy service supported by full-time and part-time spiritual leaders from different denominations. Good ––– There were very few complaints about EOL services. All staff told us they preferred to deal with issues or complaints The trust’s draft end of life care strategy took into account immediately and offered a face-to-face meeting with the the importance to plan and deliver services that provided complainant. patients with flexibility, choice and continuity of care whether they were in a hospital or community setting. Planning and delivering services which meet people’s needs We found the hospital SPCT liaised with staff and patients on the ward to ensure patients were supported in the way • London North West Healthcare NHS Trust was a newly that met their individual needs. They aimed to identify a merged service comprising three acute hospitals, three patient’s discharge needs as early on as possible so that community in-patient units (Meadow House hospice, the patient received with seamless and equitable EOLC Willesden Hospital and the Denham Unit) and wherever they chose to be supported, thus decreasing the community services for three London boroughs (Ealing, number of unplanned and inappropriate admissions to Brent and Harrow). The draft EOLC strategy stated hospital when someone was reaching the end of their life. ‘across this area around 100 people die each week, many of which will have a predicted death, even if only We found that the LDLCA was individualised and holistic to recognised in the last days or hours. Whether they reflect the patient’s needs and wishes, and took into account the views of the people who were important to them. However this was a new document and not all health

114 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

spend their final days in their own home, care home or • We reviewed the trust’s revised draft strategy for people as an in-patient, LNWHT staff have the opportunity to living with dementia. The strategy focussed on how to optimise the dying experience for both those at the end improve the inpatient experience for those living with of their lives and those left behind’. dementia through changing attitudes, the environment, • The aim of the strategy was to ensure that all people raising awareness and having clear pathways for reaching the end of their life received the most treatment and care. appropriate care and support for their own • Patients' close family members were able to stay with circumstances and avoid unnecessary hospital their relative overnight and the facilities and admissions for those that wished to be cared for outside arrangements were different for each ward at the of a hospital environment. This included providing hospital. There was no dedicated accommodation for generalist high quality EOLC which could be delivered patients’ relatives. by non-specialist health and care staff as part of their • Some senior staff expressed a concern that there were core work provided they were given education, training not enough experienced generalist staff and as a result and support to do so. the junior staff were not supported adequately in • The hospital did not have dedicated end of life beds. making flexible decisions to support patients and those Patients identified as being in the last days or hours of close to them at the end of life. For example allowing life were mostly cared for on general medical and families unlimited visiting times or and moving the surgical wards. Staff told us where possible patients patient to a side room. were moved to a side room to offer more privacy when • Staff were aware that different cultures had a different they were nearing the end of their life; and if this was not approach to death and dying. Therefore the team possible due to the number of patient on the ward and approached difficult conversations about death and their nursing needs, curtains were drawn around their dying at a pace that the patient and family could bed. understand. • Specialist palliative care beds could be arranged • Patients and relatives could access a chapel and a through the community SPCT at Meadow House multi-faith prayer room if they wished. The chapel was Hospice and was dependent on the needs of the patient not open at night. There was a full time Church of and not guaranteed. England and a Roman Catholic chaplain available. Leaders from other faiths (Hindu, Jewish and Muslim) Meeting people’s individual needs were available on a part-time and on-call basis. • We did not find any records or evidence indicating that • The mortuary staff had created an exemplary advanced care planning (ACP) had been put in place for environment in the mortuary area. They ensured each of any of the patients’ notes we looked at, or patient and the deceased were cared for in an individualised way, relatives we spoke with. However the LDCDA reminded taking into account their personal wishes and any staff to ask if there was an ACP in place, which could requests made by those close to them.We found the have been discussed with the patient’s GP. multiple systems of cross checking, which had been • We found that care planning in the last days and hours developed by the mortuary technician, ensured safe of life was individualised and holistic to reflect the practices in all areas of their work at all times. patient’s needs. The LDLCA looked at the whole picture • The hospital had a bereavement office. However, this and took into account the views of the patients and was not an ideal space as it was the first office in the carers and their spiritual, emotional, psychological and hospital’s main reception area. Bereavement staff told social needs. The patient’s preferred place of death was us people often interrupted meetings and the space was documented and this was shared with the other too small to accommodate more than one or two professionals involved in their care. However this was a people. Staff provided relatives with information, the new document and not all health professionals had death certificate and a booklet on what happens after started to use it for patients identified at end of life. death. • The SPCT reported that, in recent years, there had been • The trust had access to translation services through an increase in supporting more patients for EOLC than language line or face-to-face interpreters. There were a palliative care. number of staff who spoke other languages.

115 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

Learning from complaints and concerns possibility that a patients might die, communicating clearly and honestly with the patients and family, • End of life services received very few formal complaints. understanding the priorities of care of the patient and We were given a clear explanation of how complaints family, and delivering co-ordinated care enabling the were handled and the role of the service managers in patient to die in the place of their choosing if possible. responding to them. All staff told us they preferred to • The SPCT at Ealing Hospital were unclear about the deal with issues or complaints immediately and offered strategy and vision for palliative and end of life care a face-to-face meeting with the complainant. If they service since the merger of the hospitals within the found the issue could not be dealt with in their way they LNWHT. They were unsure how the strategy, which was supported people in making a formal complaint to the driven by SPCT at Northwick Park, would transfer to trust. services at Ealing. • EOLC group meeting minutes showed how the EOLC Are end of life care services well-led? strategy and vision was fed to the trust’s board via the clinical cabinet and any feedback was discussed and Good ––– recorded at the following EOLC group meeting. This group had representation from various directorates We rated well led in end of life care as good. such as elderly care, A&E and AHP across the trust and therefore it was possible for this information to be The service had a clear statement of vision and values, disseminated to staff at all levels through each driven by safety and quality. All staff we spoke with were directorate across the trust. committed to providing safe and good quality care. Governance, risk management and quality The SPCT regularly engaged with staff on generalist and measurement specialist wards by providing support, training and assessing the appropriateness of the care they were • A clinical governance meeting took place four times a providing. Ward staff were aware of the specialist support year where incidents and risks were explored and any available to them. trends identified. There was a clinical lead and board representation for EOLC. The trust’s draft EOLC strategy had been completed and • There was a plan to sign up to the ‘NHS Improving was in consultation stage at the time of our inspection. The Quality Transform Improvement Programme’ however strategy was developed by the trusts community and acute they required a designated service improvement lead services through regular engagement with internal and before they could do this. We noted that meeting external stakeholders, which included people who used the minutes had identified people who could possibly take service, staff, commissioners and other organisations. on this role. The transform programme streams of work Staff reported an improved emphasis on EOLC at board included: advanced care planning, electronic patient level over the last year. However the perception was that it record for OOHs care, rapid discharge home to die, five was still seen as the responsibility of the palliative and priorities for care for the last days of life and care after cancer services to drive it forward the vision for EOLC to be death. everyone’s responsibility would not be reflected. • The trust took part in a number of national audits, such as the NCDAH, which they had just completed. There Vision and strategy for this service was a plan to audit the ‘Last Days of Life Care • The trust had recently written the EOLC strategy which Agreement’ in the next few months to see how was currently in a draft format and out for consultation. accurately the document was being used and how well The strategy identified that for the trust to deliver high it supported patient care; and after a recent review of 50 quality, equitable and compassionate EOLC core sets of notes the team have decided to reviewed the principles needed to be followed across the whole of notes for the first ten deaths each month to feedback on the acute and community services. These core the quality of recording and identify any gaps, trends or principles of EOLC included the recognition of the concerns.

116 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• EOLC group meeting committee met every two months responsibility and not just that of the SPCT to ensure and included range of staff from across the trust acute this happened. Therefore they strongly encouraged and community locations including consultants, SPCNs, other staff at all levels throughout the hospital to be the medical director, the divisional head of nursing, involved in EOLC. elderly care and the resuscitation officer. Recent • Staff told us they were supported by senior managers, in minutes recommended identifying ward managers to particular the divisional head of nursing and lead nurse attend the ‘EOLC Group’ meetings; the aim was to for cancer and palliative care. They found them to be increase EOLC and the five priorities of care profile and helpful, knowledgeable and approachable. encourage ward manager to take greater responsibility • There were clear lines of accountability within the for monitoring care around their dying patients. palliative care management team based at Northwick • The SPCTs held weekly MDT meetings and bi-monthly Park Hospital. The clinical leads were enthusiastic and business and educations meetings. The team discussed proactive in helping drive forward the end of life agenda new and deteriorating patients and those that had within the trust. The clinical leads sat on the EOLC chronic illness or were of concern. They considered the steering group which sat across the whole of the trust. patients from a holistic point of view taking into account Culture within the service their social and psychological needs and assured that • The SPCTs engaged with their acute peers and other • Ealing Hospital had a community hospital atmosphere. CNSs or specialist palliative care nurses through Many staff had known one another for a number of years meetings / informal discussions. The consultants and many patients had used the hospital for a long worked within the community and at the acute time. hospitals this allowed them to address issues or share • Mergers can create uncertainty about the future of some learning with the teams and offered consistency in services. However, this did not affect the level of support for patients under their care. commitment the CNSs had to providing good end of life • A clinical forum discussed and reflected on cases that care for patients. We observed that there was some were difficult or ethically challenging. After significant relationship building with their colleagues at Northwick event analysis and death reviews allowed the team to Park Hospital. discuss the outcomes for the patient and those close to • Staff reported an open culture where they could raise them, identify any issues, learning and share good and discuss any concerns with their team and manager. practice. The specialist nurses told us they were supported by their manager and told us any issues were dealt with Leadership of service quickly. • The CNSs at Ealing Hospital expressed there was some • The SPCNs told us they perceived they were valued by distance between the services at their hospital and other the teams at the hospital who valued the support those at Northwick Park. They told us they were partly they gave. listened to but they perceived they had little control • Staff did not feel as valued by the trust wide team and over any changes or development to services. reported that all the good work they had done such as • In the last year (since September 2014) the EOLC profile training staff at induction had been dismissed as it ‘was had increased and had a “larger voice” through the not the Northwick Park way’. The leads told us they had medical director, this had given the subject” more adopted some of Ealing Hospital’s policies such at their authority”. The consultant leads told us although there ‘Last Offices (Care after Death)’ policy. was trust board representation they did not feel that Public and staff engagement EOLC yet received the level of support it required. • The SPCT told us they were passionate about all staff in • The SPCTs engaged with staff on the ward on a regular the hospital providing a safe and good quality of care for basis. The SPCT spoke positively about the engagement end of life patients and therefore it was everyone’s they had with the ward staff and thought this had shown some increase in nursing staffs’ understanding of palliative and EOLC.

117 Ealing Hospital Quality Report 21/06/2016 End of lif e c ar

End of life care

• The service found it was difficult to obtain formal Innovation, improvement and sustainability feedback from patients or bereaved relatives as survey • All staff in the SPCT, including nursing, medical, allied cards were rarely responded to. They had sent 45 health professional within end of life services surveys to bereaved relatives of which three came back. demonstrated a strong focus on improving the quality of The three comments they received were positive about care and people’s experiences through a range of local the contact they had with the CNS and there was one and national audits, pilots, surveys, feedback and comment about poor staffing levels on the wards. Staff teaching across the community setting. spoke with patients on a one to one basis to obtain • The joint working between the acute service and feedback about the service. community hospice was helping to develop and • There was patient representation on the EOLC strategy promote education in EOLC and provided patients with group to give the patients and their families “voice” in seamless support. discussions about the future strategy for EOLC across the trust.

118 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

Safe Good ––– Effective Caring Good –––

Responsive Good –––

Well-led Good –––

Overall Good –––

Information about the service Summary of findings The outpatients inspection team consisted of a CQC Overall outpatient and diagnostic services at Ealing inspector, a medical consultant, a nurse consultant, a Hospital were good because there were systems in radiographer and a nurse. During our inspection we visited place to identify record and review incidents and staff the main outpatient area and visited the clinics for were aware of how incidents should be escalated and cardiology, orthopaedics, phlebotomy, general outpatients, recorded. fractures, radiology and medical records. Outpatient and diagnostic services were visibly clean We spoke with 39 members of staff including receptionists, and there were processes to ensure cleaning was nursing staff, allied healthcare professionals such as maintained. radiographers, healthcare assistants, consultants, doctors, administrators and service managers for surgery and We saw good evidence of how the diagnostic services urology. benchmark their services through national and local audit activity and national guidelines including NICE We spoke with 12 patients at Ealing Hospital. We inspected and Royal College of Radiologists. the patient environment, and observed waiting areas and clinics in operation. We found staff were compassionate, caring and proud to work at Ealing Hospital. We saw evidence the hospital had variable performance in the National Cancer Patient Experience Survey 2014 some which placed the trust in the bottom 20% of trusts. Mandatory training was provided however staff told us face to face training was often difficult to access or attend due to clinical commitments. Hard copy records were not always available in time for clinics; the trust was aware of this and had started phased plans to integrate hard copy records in preparation for a move to an electronic record management system across all sites.

119 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

The service had a backlog of patients waiting more than Are outpatient and diagnostic imaging 18 weeks for an appointment and had attempted to reduce waiting times for patients, but financial services safe? constraints meant additional clinics had been stopped. There was a good system in place which highlighted the Good ––– patients who had waited longest and should be clinically prioritised for the first available appointments. Overall we found the safety of outpatient and diagnostic services was good. We found inconsistencies in classification of some incidents and there was a lack of a well-considered We found staff were aware of how incidents were strategy with clear goals, key staff allocated and clear escalated; there was information available about the Duty timeframes for achievement of goals for outpatient of Candour for patients and staff. There were no never services at Ealing Hospital. There was no evidence of events identified within outpatients and diagnostic services audit activity in outpatient services. at Ealing Hospital. We saw evidence of a robust serious incident investigation and learning objectives were set l following the incident. Areas visited were visibly clean, there were cleaning schedules available and equipment was identified as clean by use of green ‘I’m clean’ stickers. We found not all staff who were required to do so had completed infection control training. Resuscitation equipment was regularly inspected and records of the checks were consistently made. We saw evidence that radiology equipment was maintained and monitored for safety. Medicines were stored securely but the key holder for medicines cupboards was not always a clinically qualified staff member. We found information the majority of staff (92%/64%) were up to date with mandatory training. The majority of staff in outpatients and radiology had been trained in safeguarding and some of the staff we spoke with were aware of safeguarding issues. There was a good process in place which ensured concerning test results were drawn to the attention of referring clinicians. We saw risks associated with exposure to radiation were documented and local rules which included restricting access to high risk areas were available. We found the trust had set a target for staff completing mandatory training of 75%, this was monitored and exceeded for some training for example health and safety compliance was 92.6% for outpatients and 80.4% for radiology staff.

120 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

We saw that recruitment was challenging, but monitored • The pharmacy incident stated regular epilepsy medicine by the trust and bank staff were regularly used to cover was not dispensed. A patient's regular medication did gaps in rotas. not include epilepsy medication and the pharmacy had not queried this when they made up the prescription. However, we found evidence that incidents were The medication error was not spotted before the patient monitored in different ways by different parts of the service. deteriorated at home. The method for tracking medical records was not always • Eleven of the staff we spoke with were asked about and reliable and compilation of clinic lists was in some cases were aware of the trust incident reporting procedure cumbersome and included printing hard copies of test using Datix and four of them explained the Duty of results which were available electronically. Candour. Incidents Cleanliness, infection control and hygiene • We were not assured incidents were consistently • Disposable curtains were used in the main outpatients monitored and managed. area; these were dated and we saw green ‘I’m clean’ • The trust provided a copy of the incident tracker for stickers on equipment in the department. Ealing Hospital and which showed there five serious • There was a cleaning schedule and cleaning incidents being investigated between 27 February 2014 instructions were available in the outpatient and 23 September 2015. These were difficult to department. We did not see evidence of audit of reconcile with the Datix incidents and appeared to be cleaning. different. Of these, two related to radiology and one • There were no occurrences of clostridium difficile each related to pharmacy, cancer services and one attributed to outpatient services between April and July related to the outpatient fracture clinic. 2015. • The trust had an incident and near miss reporting policy • Endoscopes in the ear, nose and throat department dated February 2015. This policy contained a list of the were cleaned using Tristel wipes and there was a untoward events classed as never events. There were no tracking and recording system in place. reported never events relating to the outpatients or • Information from the trust showed 91% of outpatient diagnostic departments at Ealing Hospital. Never Events staff and 61.9% of radiology staff had completed are serious, largely preventable patient safety incidents infection control training. that should not occur if the available preventative • Alcohol hand gel dispensers were available at entrances measures have been implemented. to outpatient clinics. • We saw the root cause analysis investigation for a • We observed phlebotomy staff wearing personal pressure ulcer sustained by a patient in fracture clinic in protective clothing for example aprons and disposable June 2014 was robustly investigated and gloves. recommendations included how to share learning • Radiology had completed a hand washing audit which within the team. We did not see evidence that this had showed doctors were 96%, nurses 100% and been shared with the team. radiographers 98% compliant. No recommendations • Serious incidents were categorised as severe or were made about these results. moderate harm. There were four serious incidents • Clinical staff wore short sleeved uniforms in colours that attributed to the outpatients and diagnostic services denote their role. For example white for phlebotomists. between 1 July 2014 and 31 July 2015. Records showed Environment and equipment serious incidents were not wholly attributed to outpatients, but were referenced under the speciality • Resuscitation equipment was available in cardiology, and this made identifying serious incidents related outpatients and orthopaedic clinics. We saw evidence specifically to outpatients difficult. they were regularly inspected by staff and records of • Of the serious incidents identified, three related to these checks were consistently made. delayed diagnosis in radiology and one related to • We saw evidence that personal protective wear pharmacy. including lead aprons were checked for defects.

121 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• We saw evidence that a maintenance schedule and • The medical records manager told us she tried to ensure contract was in place for radiological equipment at records were available in time for clinics. Ealing Hospital covering the period October 2013 to • A temporary medical record was created when the main October 2016. patient notes file could not be found. Temporary patient • However, a consultant in the ear, nose and throat clinic records were also held within the medical records (ENT) expressed concern about the limitations of the department and these were where stored in the same number of available endoscopes; there were two shelves and amalgamated when the files were next endoscopes that were used to treat up to 28 patients. picked for a clinic. • Radiology staff told us that one computerised • Medical records staff compiled a list of records seven, tomography (CT) scanner was old, had been three and one day before clinics and included printed condemned but remained on site pending procurement off test results which were available electronically. Our of a replacement. Staff told us space was at a premium inspectors believed the practice of printing off test and if they had the condemned scanner removed before results electronically available was cumbersome and a new scanner was made available they might also have unnecessary. to relinquish the space. The radiology manager had • The method for tracking medical records was not always provided the trust board with a business case for reliable. Notes were stored in the medical records replacement scanner in May 2015 however minutes department and were collected by medical records staff from the radiological protection committee in in preparation for outpatient clinics. Notes had an September 2015 showed no decision had been made to electronic barcode tracking system for traceability purchase a replacement. however, they were not always found because staff did • The service had an annual plan for audits in radiology, not always use the tracking system to sign records in or this included audits relating to IR(ME)R. Staff told us out of a department. The medical records manager told their next IR(ME)R audit was due to be done in February us this was often because a clinic or department had 2016. borrowed the records to complete for example a letter • The IR(ME)R audit for Ealing Hospital on compliance to be sent to the patient’s General Practitioner (GP) but with IR(ME)R report from March 2015 showed ‘significant had not used the electronic system to sign them out. assurance’ that the guidance relating to ionising • The medical records managers told us missing records radiation regulations were being followed. were a daily occurrence and they used the Datix system to report missing or lost health records. We asked these Medicines managers to show us an example of reporting however • We found medication was appropriately and securely neither could remember the correct password and they stored in the cardiology clinic, outpatient clinic and were not able to access the Datix system. phlebotomy, and fridges containing medicines which • The patient records programme manager told us the required chilling were consistently monitored and board had reviewed a three phase plan to unify patient recorded without gaps. records processes starting by unifying the hard copy • However, staff in the ear, nose and throat (ENT) clinic notes and ending with implementation of an electronic told us there was no registered nurse in the clinic and patient records system. He showed us a copy of the the healthcare assistant held the keys for the drug phased plan which had been presented to the board in cupboard. The healthcare assistant was also September 2015. We did not see evidence of the responsible for allocating the prescription pads to the decision taken by the board about the phased plan. treating consultants. We were told a record of the Safeguarding numbers of prescriptions handed out was made, but we didn’t see the record and were told this was not audited. • Information provided by the hospital showed 93.2% of We were concerned that an unqualified member of staff radiology staff required to undertake safeguarding was given this responsibility. adults training Level 1 had completed this training and 76.7% of staff required to undertake safeguarding adults Records training level 2 had completed this.

122 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• Information provided by the hospital showed 82% of 91%), manual handling Level 1 85.7% and Level 2 86.%, outpatient staff required to undertake safeguarding Mental Capacity Act Level 1 78.3% and prevention of children Level 1 had completed this and 75.6% of staff terrorism known locally as ‘prevent’ 51.9%and required to undertake safeguarding children training information governance 80.4%. Level 2 had completed this training. • Radiology outpatients staff had completed training as • One band 5 nurse in children’s outpatients told us she follows: equality diversity and human rights 67%, fire had been trained in safeguarding Level 3. We did not see safety 74.6%, health & safety 80.4%, major incident evidence that paediatric staff had undertaken awareness 35%, infection control 61.9%, manual safeguarding training Level 3. handling level 1 56.5%, Mental Capacity Act Level 1 60%, • Three of the staff we spoke with told us they were up to prevention of terrorism known locally as prevent 38% date with safeguarding training and were aware able to and information governance 54.4%. describe previous safeguarding concerns that had been • Three staff told us they were up to date with mandatory escalated. training. • We saw evidence on the outpatient noticeboard that • We saw evidence in minutes of the clinical governance chaperones were available. meetings that the trust monitored the update of • We saw evidence the radiologists had a procedure mandatory training. which ensured urgent reports were escalated to medical • However, a further three told us there were gaps owing secretaries who in turn draw urgent information to the to clinical commitments making attending face to face attention of the referring specialist. training more difficult than electronic self-learning. • However, staff in the ear, nose and throat (ENT) clinic Assessing and responding to patient risk told us children were not seen on the same day as adults. However, on the day we inspected there were • The trust had an appropriate process whereby senior five children waiting for appointments. We drew this to clinicians reviewed the data about patients waiting for the attention of the matron who told us she would take overdue appointments and these were graded this up with her manager. according to a low, moderate or high risk of harm and • Staff in the ENT clinic told us of another incident when the trust provided sub-specialty clinics for patients children were waiting to be seen and a mental health where a delayed follow-up would lead to clinical risk. patient was brought to the department restrained in For example Glaucoma. handcuffs. We asked the matron about this, she told us • The radiation protection supervisor told us that a at the time there was no method for identifying patients radiation protection committee was established when with particular needs prior to their attendance and she the trust merged, key documents including the local was attempting to set a system up. rules for radiation protection were updated during the summer of 2015 and (radiation) dose reference levels Mandatory training were being revised. • The trust target for integrated clinical services teams’ • We saw evidence of the updated local rules for radiology completion of mandatory training was above 75%. and they cross referenced the Ionising Radiation Mandatory training for this trust included equality (Medical Exposures) Regulations (2000), (IRMER). The diversity and human rights, fire safety, health & safety, local rules included the steps required to restrict access major incident awareness, infection control, manual to the areas where radiological testing was carried out. handling level 1 and Level 2, Mental Capacity Act Level 1, • The outpatients risk register identified five issues of prevention of terrorism (known locally as prevent) and concern including lack of capacity, temperature in the information governance. women’s clinic environment, lack of availability of • Outpatients staff had completed training as follows: complete medical records, overbooking clinics and equality diversity and human rights 83%, fire safety absence of a dedicated plaster sink in the plaster room. 73.4%, health & safety 92.6%, major incident awareness • Each risk register entry had a time bound action point to 57.8%, infection control clinical 57.8% (non-clinical mitigate the risks. For example the trust used fans and had obtained quotes for fitting air conditioning in the women’s clinic area and

123 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• Lack of availability of medical records was • We saw evidence in the radiology consultants meeting cross-referenced in the main trust risk register. We saw minutes for 9 July 2015 there were two radiologist that an outline business case had been made to the vacancies at Ealing Hospital and three locum posts. The board in September 2015 for purchase of an electronic minutes recorded applicants for the radiologist posts document management system (EDMS). We did not see had been shortlisted for interview in September 2015. minutes for the September board meeting. Major incident awareness and training Nursing staffing • We saw evidence all staff were required to complete • Outpatients are part of the integrated clinical services anti-terrorism and major incident awareness training. division. Information provided by the trust showed there • The trust had a business continuity plan dated January were consistent shortfalls in the nursing establishment 2015. None of the staff we spoke with mentioned this of up to 20%. plan. However, the plan included a flow chart to • The outpatients general manager told us that they did cascade information between other relevant parties not use agency nursing staff however they did use bank should a disruptive incident occur such as loss of staff and we saw evidence demonstrating bank staff electricity supply. The flow chart included numbers for cover for some gaps in the rotas. other agencies such as ambulance and fire and rescue • We saw nurse staffing rotas for May to September 2015. services. These showed the names and grade of the nurses, but not the clinics assigned to them. There were regular Are outpatient and diagnostic imaging gaps owing to sickness absence. For example week commencing 5 September there were two healthcare services effective? assistants and one band 5 nurse sick for the week. We We found of the effectiveness of diagnostic services was saw that there were three bank healthcare assistants good however we found less evidence that outpatient who regularly covered the outpatients department, but services were good. could not identify if this was to cover gaps owing to sickness absence or vacancies. We saw evidence the radiology department had • Radiology staff told us they work across all sites. We appropriate systems, key documents for managing and asked for copies of rotas, we saw the rotas for Northwick responding to risk and participated in audit of some Park and Central Middlesex Hospitals and that national guidelines. We did not see evidence that demonstrated staff worked between these two outpatients at Ealing Hospital participates in audit activity. hospitals. We did not receive rotas for Ealing and could We found the trust provided training for people with not corroborate that staff from radiology in Ealing work particular vulnerabilities for example dementia through at either of the other hospitals run by the trust. Mental Capacity Act training and staff we spoke with • Staff perceived a level of inequality of the number of described how they supported people with dementia. clinical nurse specialists compared to Northwick Park Hospital. We did not see evidence of the numbers of Results from the National Cancer Patient Experience Survey clinical nurse specialists at either Ealing or Northwick 2014 showed Ealing scored well in explanations to patients Park Hospital. about their cancers and less well in providing clear information for patients to take from a consultation. Medical staffing • The assistant director of nursing told us there were no Evidence-based care and treatment medical personnel directly employed by outpatients. • The radiology department carried out a variety of Medical staffing was provided by the specialities; for national and local audits of guidelines including the example in cardiology, there were six consultants who Royal College of Radiologists referral guidelines and had split contracts and also worked for other west British Thoracic Society guidelines of suspected London hospitals. pulmonary embolism and NICE guideline no 144 (Venous thromboembolic diseases).

124 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• Radiographers followed guidelines based on NICE summer 2013 entitled ‘Making the best use of clinical guidance for screening and diagnosis of bowel cancer radiology’. This audit cross -referenced NICE guideline which also followed Royal College of Radiologists 144 for venous thromboembolic diseases. Results Guidelines. showed the hospital changed the form used for referrals • We saw a copy of the local rules for the imaging to ensure key risk information was included to indicate department. These had been revised and updated in suspicion of a pulmonary embolism. This was August 2015 and included how to restrict access to high re-audited and identified improved information was risk areas and how to ensure patients and staff were provided on the revised referral forms. protected from unintended doses of radiation. The local • We saw evidence of an audit of radiology requests was rules included key safety information about exposure, carried out in the summer 2014 against the same Royal for example to ensure that x-rays were clinically justified College guidelines. The audit compared paper versus and staff wore personal protective monitors and electronic referral information and concluded that equipment such as lead aprons. electronic was more complete than paper. • The nurse in charge of outpatients told us an audit of • The audit included review of cross-checking the patient waiting times at clinic was ongoing. This was not appropriateness of the requested scan .There was a on the priority audit list seen for surgery and critical care target for cross-checking of95% which was met and a or the Integrated Clinical Services audit report August 90% target for ensuring the scan was justified was 2015. exceeded (98%). Recommendations were made to incorporate more time for cross-checking in job plans Pain relief and to promote electronic referrals over paper. • None of the 12 patients we spoke to raised pain relief as • However, we did not see evidence of participation in the a complaint and none of the complaints related to Imaging Services Accreditation Scheme (ISAS). outpatients services were about pain management. • We did not see evidence of participation in the • The trust scored well in the National Cancer Patient Improving Quality in Physiological Services (IQIPS) Experience Survey 2014 for questions related to pain accreditation scheme. management for outpatient care: ‘Staff definitely did • We did not see evidence of audit activity within everything they could to help control pain’ 80% and outpatients departments. ‘Staff definitely did everything to control side effects of Competent staff chemotherapy’ 92%. • We were told there was no pain management clinic at • Information provided showed across the trust 92% of Ealing Hospital however a trust wide pain management outpatient staff and 64% of radiography staff had an up clinic was held at Central Middlesex Hospital. to date appraisal. • We saw that completion of mandatory training was Patient outcomes acknowledged on the trust risk register. The steps for • The results of the National Cancer Patient Experience mitigating the risk included the introduction of an Survey 2014 showed this hospital scored well for the electronic learning system and weekly and monthly following questions: ‘Staff gave complete explanation of monitoring of compliance at divisional level. purpose of test(s)’ 8%; ‘Staff explained completely what • Three staff in medical records told us about training would be done during test’ 90%; ‘Patient told they could sessions that took place on alternate Fridays for one bring a friend when first told they had cancer’ hour to ensure medical records staff were updated with 67%;’Patient completely understood the explanation of key information relevant to their department. what was wrong’ 75%. • The radiology manager told us they work with the Scores were less positive for ‘Given easy to understand University of Hertfordshire who send students to the written information about test’ 73% and ‘Given complete trust and many of the graduates stay. explanation of test results in understandable way’ 71%. • We saw evidence Ealing Hospital participated in audit of Royal College of Radiologists Referral Guidelines in

125 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• In the radiation protection advisor’s report February • We also saw that the radiology department had audited 2015, there was evidence staff had been IRMER trained, ‘Concordance rates between radiographers and there were annual updates and further on-line radiation radiologists in the decision to give contrast’ between protection training was available through the radiation June 2014 and June 2015 and that this results showed protection advisor and supervisor. agreement of the appropriateness of this in all but one • We saw evidence on the corporate risk register that referral. weekly monitoring the uptake of mandatory training • A cardiac research technician told us about a research commenced in September 2015, we did not see project investigating the risk factors for heart disease evidence of how the trust would ensure all staff had an and diabetes in the local community. Patients were up to date appraisal. referred by their GP. The London Life Sciences • We were told the lead radiographer had advanced Prospective Population Study known as the LOLIPOP training in CT reporting, but was often not able to carry study had been running since 2002 and comprises out this work owing to staff shortages. The radiology detailed health assessments for people living in West manager told us there was a national recruitment London. Up to 30 patients a day were screened by problem and they supported training of band 5 Ealing hospital. The research was co-funded by the radiologists to enable promotion within the trust but National Institute for Health Research (NIHR) and a this then leaves a gap in band 5 staff. This was not pharmaceutical company. identified on the trust risk register. • The physiologist working in cardiology told us patients’ • The radiology manager told us freeing up staff to GP’s could make referrals for same day service to a complete training was a challenge owing to vacancies walk-in echocardiogram service (ECG) service. and clinical commitments. Seven-day services • Revalidation of doctors’ information was provided for the whole trust. This information showed there were 433 • The radiology manager told us diagnostic services staff doctors requiring revalidation across the trust. It was not had begun to function as an integrated team and possible to tell from this information which of the 69 worked across the three trust hospital sites. They had doctors’ revalidation had been deferred pending more changed their working patterns to cover on-call working information or the three fitness to practice panels for evenings and weekends. related to medical staff practising within the outpatient • Magnetic resonance imaging (MRI) and CT scanning was departments. provided 8am to 8pm seven days a week. The rotas included named staff to cover on-call work for CT Multidisciplinary working scanning but not MRI. • We saw evidence in June 2015 clinical governance • However, we did not identify any out of hours outpatient minutes pharmacy staff shared with phlebotomy staff clinics run from Ealing hospital. who passed on risk information to pathology colleagues Access to information about the risks associated with multiple and different identification information for individual patients. • The IT department staff told us about problems which • We were told that the cardiology service offered a had been identified earlier in the year when a new consultant led one-stop clinic each weekday which saw radiology information system (RIS) was implemented as three patients. part of the implementation of the business case above • We saw evidence that the radiology department audited and which had caused a backlog because staff were the appropriateness of general practitioner (GP) referrals unfamiliar with the new programme and took longer to to prevent unnecessary exposure to radiation doses complete tasks. between March 2014 and March 2015. The results • A senior radiology manager told us the backlog often showed that 100% of referrals were cross-checked for prevented them from reporting results in real time due appropriateness by a radiologist and 97% of the first and their goal was to eliminate the backlog and report requested test was carried out as the most appropriate first investigation.

126 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

results in real time. The radiology manager told us there • Staff in outpatients and diagnostic services were remained a backlog of approximately 2400 test results. multi-cultural and demonstrated passion for their roles. We saw this risk represented on the corporate risk For example a band five nurse in outpatients told us she register. had recently returned to work for the trust in outpatients • We saw evidence on the trust risk register of the two although she had trained in paediatrics, but said serious radiology incidents but not the backlog of tests working in outpatients was very worthwhile. which required reporting. • Mostly we saw staff interacting with patients in a caring, compassionate way. For example we saw staff in Consent, Mental Capacity Act and Deprivation of outpatients informing patients of waiting times for Liberty Safeguards clinics. • Information provided showed the trust provided Mental • Trust results for the friends and family test (FFT) for July Capacity Act Level 1 training to staff across the trust and 2015 showed 97% of 387 respondents were highly likely 78.2% of outpatient staff and 62% radiography staff or likely to recommend outpatients at the hospital. were up to date with this training. • A staff nurse in the ear, nose and throat department told • Six members of staff told us how they supported people us she ensured patients who had been in the who lacked capacity. For example supporting those with department for up to four hours were offered food and dementia or learning difficulties by seeking the advice of drink. the learning difficulty champion within the department. • We saw six completed FFT forms in the cardiac catheter • One member of staff also told us that people with laboratory had been completed and stated they would dementia were fast tracked to see the consultants recommend the hospital. without having to wait with other patients. • The noticeboard in outpatients contained information • The trust had a policy for consent to examination or about staffing levels, a picture and contact details for treatment which was last reviewed in September 2012. the matron and how to contact the patient and advice • There was evidence the trust had audited consent, but and liaison (PALs) team to provide feedback or raise this was limited to in-patient wards. We did not see concerns. evidence of a consent audit in outpatients. • We saw that observations such as weight and blood pressure monitoring were done in a room with the door Are outpatient and diagnostic imaging closed to assure patients privacy and dignity. services caring? • The trust scored well in the National Cancer Patient Experience Survey 2014 for questions related to outpatient care for ‘Doctor had the right notes and other Good ––– documentation with them’ 96%. • However, we also saw evidence from the National Overall we rated caring by staff in outpatient and Cancer Patient Experience Survey 2014 which placed the diagnostic services as good. hospital in the bottom 20% of trusts for the question ‘Patient reported they were told sensitively that they We observed staff interact with patients in a positive, had cancer’. friendly and compassionate manner. Understanding and involvement of patients and those Patients’ privacy and dignity was maintained during checks close to them which included weight and blood pressure were done in consultation rooms with doors closed. • Patients with whom we spoke with did not raise concerns about involvement in their care. However, we also saw evidence from the National Cancer • Patients’ privacy and dignity during checks which Patient Experience Survey 2014 which placed the hospital included weight and blood pressure were done in in the bottom 20% of trusts for the question consultation rooms with doors closed. ‘Patient reported they were told sensitively that they had cancer’. Compassionate care 127 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• The trust scored less well in the National Cancer Patient Staff were able to describe how they supported patients Experience Survey 2014 for questions related to with vulnerabilities such as patients living with dementia. outpatient care for ‘Family definitely given all Information was available in the outpatients department to information needed to help care at home’ 56%. This help patients provide feedback or make a complaint. placed the trust in the bottom 20% of trusts. Following implementation of a new IT system that caused a • We did not speak to any relatives of patients on the day backlog radiology staff changed their normal working we inspected. pattern to be able to open radiology between 8am and • However, three patients we spoke with told us about the 8pm as part of the measures to reduce the resulting long waits in clinics. backlog caused by implementation of the new IT system. Emotional support However, we saw evidence that half of the complaints • One patient told us they attended outpatients regularly, patients had made about outpatients and diagnostic rarely waited more than half an hour and were services at Ealing Hospital were the result of poor sometimes late for their appointment, but were still communication between the hospital and patients or other seen. departments within the hospital. • We saw evidence of involvement of other teams on the The trust had a backlog across most outpatient specialities waiting room notice board. For example how to access of 386 patients who had waited more than 18 weeks, for an interpreter or how to contact the Patient Advice and example the longest waits were for cardiology services. The Liaison department (PALs). trust had high did not attend rates (DNA) and had piloted • However, the trust scored less well in the National sending patients text reminders of their appointments, but Cancer Patient Experience Survey 2014 for questions this had been terminated without being evaluated. related to outpatient care for ‘Hospital staff definitely gave patient enough emotional support’ 66%. This Additional clinics at weekends had been provided to placed the trust in the bottom 20% of trusts. address some of the backlog, but we were told these would cease in November due to financial constraints. Are outpatient and diagnostic imaging Service planning and delivery to meet the needs of services responsive? local people • Patients referred to outpatients at Ealing Hospital could Good ––– choose to attend outpatients there or at one of the two other hospitals run by this trust, Northwick Park Overall we judged that responsiveness of outpatient and Hospital or Central Middlesex Hospital. Patients with diagnostic services was good. urgent needs, for example two-week wait cancer Patients referred to the outpatients service were given the patients were given the first available appointment first available appointment at Ealing Hospital but could regardless of location. choose to attend one of the other two hospitals run by the • Staff told us there had been a surge in demand for trust. We saw evidence that patients would recommend outpatient services across the trust. The trust provided the trust to friends and family. We saw evidence that trust information that showed there had been 569,126 provided patient information within the outpatient clinic. outpatient referrals in 2013-14 and 790,724 in 2014/15. This equated to a 39% increase. The trust had a process for identifying the patients near to • The trust had high did not attend (DNA) rates of having waited 18 weeks and escalated this information to between 5.5% for oncology and 20% for respiratory the speciality clinics to which patients’ had been referred. medicine. Cardiology staff told us patients who do not We were told about a one-stop clinic run by cardiology. attend but were suspected of having cancer were offered a second appointment. This was confirmed in the patient access guidelines document dated 13 March 2014.

128 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• Patients GP’s were sent a letter advising of patients who divisions were achieving the following: integrated did not attend for an appointment. clinical services 98.9%; Women and children 96.5%; • Cardiology staff told us that non-urgent patients who do Medicine 93.8% and surgery 91.4% of patients’ were not attend were not routinely offered a second given an appointment within two weeks. appointment. • Service managers for surgery and urology told us extra • Patients attending for catheterisation appointments for clinics had been offered to address the backlog, but example for angioplasty or angiography in the these would cease in November 2015 due to financial catheterisation laboratory attended, were assessed by pressures. The trust monitored the backlogs on a daily nursing staff the week before procedures and checked basis and we were told held a weekly meeting across all for bacterial infections such as MRSA. sites to discuss progress. However, the weekly meeting • The trust trialled using text messages to remind patients had been cancelled during the week we inspected. of their appointments to reduce the DNA rate. The chief • The cardiology service delivery manager told us patients executive and the outpatients general manager told us waiting for cardiology treatment required many about the pilot. . The medical records manager told us it diagnostic tests and this and patient cancellations didn’t work and the outpatients general manager told sometimes delayed treatment. us it was stopped because of financial constraints. We • The service managers’ told us consultants were looking asked to see the evaluation evidence for the text pilot to discharge patients for whom test results were normal however no evaluation of the pilot had been completed. and no follow up appointment was required since extra • We saw notice board information in the main clinics were stopped. They told us there were weekly outpatients area identifying the staff working there and meetings to discuss progress reducing the backlog. with contact details for raising concerns if required. • The trust had consistently failed to meet the 95% target • New seating had been purchased for the main of patients referred to treatment within 18 weeks within outpatients department at Ealing Hospital. the divisions of surgery and medicine. Information on • Some areas within the outpatients department were the trust divisional performance scorecard showed that more suitable than others. For example we found the year to date (July 2015) the trust had achieved 92.04% cardiology clinic had a sufficient waiting area, which was for surgery and 93.88% for medicine. quiet on the day of our inspection and other rooms • Diagnostic services performed better at 99.17%. used for consultation were well equipped and clean. However, the radiology service manager told us there • However, the fracture clinic was busy, cramped and on remained a backlog of approximately 2400 test reports the day we visited patients were queueing in corridors across the trust. whilst waiting for treatment. • The introduction of a new electronic radiology information system (RIS) for diagnostic testing including Access and flow radiology in June 2015 resulted in a backlog of patients • The trust had a backlog across the board of patients waiting for tests and an increased need for manual being referred for outpatient treatment. Hospital data validation of electronic data. This was reflected on the showed 386 patients across all specialities were waiting corporate risk register. more than 18 weeks for an appointment. • Radiology staff changed their normal working pattern • The percentage of patients waiting over 18 weeks for to be able to open radiology between 08:00 and 20:00 as treatment ( June 2015) ranged from the lowest in part of the measures to reduce the resulting backlog colorectal surgery (11.9%); gastroenterology (17.2%); caused by implementation of a new IT system. The oral surgery (23.9%); general surgery (38.9%) and disruption to the service was reflected on the risk cardiology (46%). register and 384 test reports were outsourced to other • The service had a patient access guideline which providers. referred to the national two week maximum waiting • Two patients we spoke to told us they had waited 50 target for appointments for patients who required minutes and half an hour respectively since arrival. treatment of malignant disease. We saw that the Meeting people’s individual needs divisions monitored the achievement of two-week referrals on a monthly basis and in July 2015 the

129 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• The general manager of outpatients and two outpatient visually impaired patient within in a wheelchair in the staff told us they had telephone access via ‘pink’ corridor of the orthopaedic clinic. We asked if a risk telephones for people requiring translation services. assessment had been done for this area and were told • Five members of outpatients staff told us patients living this was yet to be completed. with dementia or patients with a learning disability were • Results of the national cancer patient survey 2014 seen more quickly to avoid them having to wait and to showed the trust performs less well than the national minimise anxiety, but they were not aware of any average for ‘clear written information about what attempts to make information known about these should / should not do post discharge’. patients prior to their appointments We identified Learning from complaints and concerns information on the trust website about a commitment to make reasonable adjustments for people with special • The trust used the Datix system to record complaints needs. This included health passports for people with alongside incidents and we saw evidence there were learning difficulties. However, none of the staff we spoke further incidents related to outpatient and diagnostic with mentioned these. services between 1 July 2014 and 31 July 2015. • We observed nurses updating patients about waiting • The trust had a complaints and concerns policy. We saw times. a copy dated October 2014 and this policy had been • Waiting times were displayed on the notice board in the updated to take account of the Francis enquiry main outpatients department along with other patient recommendations. The complaints procedure flow information, for example patient advice and liaison chart provided by the trust showed complaints should (PALs) information on how to complain and what to do if be logged on the Datix incident reporting system. the patient required an interpreter for their consultation. • There were 40 complaints about Ealing outpatient • We saw evidence that patients would recommend the services between November 2014 and July 2015. The trust to friends and family. We saw evidence that trust information was in summary rather than detailed provided patient information within the outpatient format. Twenty related to poor communications for clinic to assist patients. For example how to contact the example: ‘a patient attended a dermatology patient advice and liaison service (PALs). appointment and was left distressed by the treatment • We were told that there was a ‘one-stop’ cardiology received as well as lack of communication regarding clinic which saw up to three patients daily. biopsy results’. Seventeen related to delayed or • One phlebotomist told us the cardiac clinic provided an cancelled treatment, for example a patient experienced anti-coagulation clinic and this reduced waiting time for delay obtaining an appointment for removal of kidney phlebotomy patients. stones; two related to medication changes and one • Some areas of outpatients were cramped and we related to an accidental fall in the ear, nose and throat observed a partially sighted patient in a wheelchair clinic. waiting in the corridor for the orthopaedic clinic. We • Thirty-one complaints had been closed mostly within asked this patient if that was satisfactory, he told us he one month. Nine remained open, two had unexplained was blind and didn’t know he was in the corridor. Staff initials in the outcome field but all of them with told us there was not room in the waiting room for the remained open with no outcome detailed. wheel chair. • A senior cardiology nurse told us that patients were • There was a rapid access for chest pain clinic that aimed more likely to complain about administrative errors to see clinics had been withdrawn owing to financial than clinical care. constraints. A physiologist told us meeting the two week • We did not identify any staff who were aware of the new target for the rapid access chest pain clinic would be complaints procedure. more difficult in future. Cardiology services were not managed by the outpatient department and not Are outpatient and diagnostic imaging reflected on the outpatients departmental plan. services well-led? • The phlebotomy manager told us that the space was not always sufficient to meet the needs of patients. We observed this space was cramped. We observed a

130 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

which showed mandatory training compliance, risk register reviews, audit of NICE guidelines, incident Good ––– reports and safety alert bulletins were discussed. The agendas included embedded documents, for example Regular meetings took place to review mandatory training the divisional risk register, clinical audit report, training compliance, risk register reviews, audit of NICE guidelines, information and for August a risk assessment template incident reports and safety alert bulletins. for X-Ray & CT. • The evidence we saw showed that a clinical governance The service scored well in some of the NHS staff survey meeting system was in place at which key risk 2014 indicators, for example in the ‘Percentage of staff information was discussed and included risk feeling satisfied with the quality of work and patient care assessment, risk register reviews and other key safety they are able to deliver’. information. Not all the specialities which provided an outpatient Leadership of service service are managed by the integrated clinical services division. The clinics which are not part of the outpatients • Staff from orthopaedic, general outpatients, radiology, department for example neurology, cardiology, ENT, phlebotomy and medical records told us managers dermatology, respiratory and haematology report to the were approachable and supportive and one healthcare divisional director for medicine. Vascular, breast care and assistant in phlebotomy described the outpatient sister urology departments report to the divisional director for as “brilliant” stating further that she had made positive surgery. changes and keeps staff well informed. • Staff in in outpatients services told us the appointment Vision and strategy for this service of the matron had improved the profile of outpatients • The service had a draft clinical strategy dated for example through accessing funding for new seating September 2015. This stated that quality improvements in the waiting areas. would be required to create a one stop Patient Access • The merger last year provided an opportunity to assess Centre for all patients. The plan included for example the skill mix and structures for managing outpatient merging booking centre teams across all three acute services including medical records and booking hospitals, reducing did not attend (DNAs) by texting services. The trust had recently identified more work service users and developing an emailing system to was required to streamline processes and had begun to reduce paper and postage costs. The divisional general identify key roles and responsibilities. We found the lead manager, the divisional lead nurse and the general roles and accountability of the present leadership manager were named as the responsible leads for the structure were currently split between four divisions. plan. Culture within the service • The trust had an information management and technology (M&T) strategy dated June 2015 led by the • Most of the staff we spoke with were enthusiastic about director of information technology (IT). The strategy the trust and predecessor organisations. confirmed the trust board had agreed in principle in • Some staff we spoke with perceived inequality between March 2015 to implement a single digital record keeping Ealing and Northwick Park Hospitals, for example about system. the numbers of clinical nurse specialists, work • The service had a divisional business plan 2015-16 led allocation and grading of medical records staff. For by the divisional clinical director. example we were told by radiography staff they had capacity to provide a service to some of Northwick Park Governance, risk management and quality Hospital patients, but were not given this opportunity. measurement Public engagement • We saw agendas for a London North West Healthcare NHS Trust Legacy Ealing Clinical Support Services & • The trust used social media to communicate from the CLIPS Clinical Governance Group for meetings that took trust website. None of the staff we spoke with made place on 12 February, 18 June and 13 August 2015, reference to this form of communication with patients.

131 Ealing Hospital Quality Report 21/06/2016 Outp atients and diagnostic imaging

Outpatients and diagnostic imaging

• We held a listening event in October 2015 to gain the Innovation, improvement and sustainability views of patients who used this hospital. One patient • Booking staff and service managers told us about told us the cardiology department had been excellent. attempts underway to reduce waiting times for patients However, some feedback focussed on poor transport including consultant review of diagnostic tests in links and long waits for treatment upon arrival for urology and surgery and discharging patients with appointments. normal range test results who did not need to be seen • We saw evidence in the NHS Choices web site patient for a follow up appointment. They used a patient feedback about outpatient and diagnostic services tracking list which was checked daily and reminders related to a good service in cardiology and a good were sent by the trust 18-week referral to treatment lead experience of ultrasound but other feedback was mostly for patients who had waited almost 18 weeks without about long waiting times and one patient was unhappy having an appointment. about poor access for physically disabled people. • We were told about planned improvements which Staff engagement included moving to an electronic document management system. • Radiology staff told us relationships with Northwick Park • We were told by managers attempts to remind patients colleagues had been positive since the merger and by text about their appointments and extra clinics to anecdotally they had the lowest sickness absence rates reduce backlogs had been discontinued owing to in the trust owing to staff satisfaction in radiology. We financial constraints. did not look at staff sickness absence rates.

132 Ealing Hospital Quality Report 21/06/2016 Outst anding pr actic e and ar as f or impr ovement

Outstanding practice and areas for improvement

Outstanding practice

• We saw several areas of good practice or progress • The play specialists in services for children including: demonstrated how they could make a difference to the service and its environment in meeting the needs of • caring attitudes, dedication and good the children and young people. This included an multi-disciplinary teamwork of clinical staff. outstanding diversional therapy approach for children • good partnership working between urgent and and young people, which was led by the play specialist emergency care staff and London Ambulance staff. and school tutor. • good induction training for junior doctors. • evidence of good antibiotic stewardship, particularly • research projects into falls bundles, stroke trials and at Ealing pharmacy, with regular reviews of need; and good cross site working in research. the roll out of drug cabinets across certain parts of the • Staff told us there were good opportunities for training trust with secure finger print access. and career development. • patient satisfaction data collected by iPAD in one • We found the specialist palliative care team (SPCT) to pharmacy location be passionate about ensuring patients and people close to them received safe, effective and good quality care in a timely manner.

Areas for improvement

Action the hospital MUST take to improve • Improve hand hygiene to show audits resulting in above 90% compliance and leading to 100%. • Instigate and continue an improvement plan in the • Develop care plans which enable individualised emergency department to achieve mandatory targets information to be reflected and acted upon by staff. including the 4 hour treatment target. • Improve referral to treatment times in surgery. • Set an action plan to address poor performance • Improve theatre utilisation and efficiencies related to against College of Emergency Medicine audit start and finish times. measures on pain relief, renal colic, fractured neck of • Implement WHO patient safety checklists in all surgery femur and consultant sign off. settings • Improve mandatory training levels and support for all • Formally define care pathways in surgery. staff to reach trust targets of 95%. • Improve provision of equipment for surgery. • Ensure COSHH assessments and arrangements are up • Ensure improvement in data completeness for to date and maintained. patients having major bowel cancer surgery in line • Ensure staff receive training and have their knowledge with the England average of 87% and up from the assessed in Mental Capacity and Deprivation of Liberty hospital performance of 30%. safeguards. • Review the surgical environment with respect to the • Review infection prevention and control (IPC) practice needs of individuals living with dementia. and ensure correct IPC dress protocols are observed • Improve ventilation in the endoscopy department. for all staff. • Implement a hospital wide training programme to • Ensure patients’ nutrition and hydration is monitored ensure ward staff understanding of end of life care and with fully completed records on medical wards. the Last Days of Life Care Agreement (LDLCA). • Improve record keeping with respect to fluid balance • Improve signage for patients in outpatient clinics. charts. • Review all arrangements and processes for the care • Review IPC and improve cleanliness of equipment and and treatment of children at Ealing ED. fixtures on Ealing medical wards.

133 Ealing Hospital Quality Report 21/06/2016 Outst anding pr actic e and ar as f or impr ovement

Outstanding practice and areas for improvement

• Take steps to examine and improve staff morale on • Address items on the OPD risk register including lack of Ealing medical wards. capacity, lack of complete medical records, • Review drug round timings to minimise medicines overbooking of clinics, and the absence of a plaster errors sink in the plaster room. • Review therapy visits on wards to prevent and • Review medicines temperature control issues across minimise patients missing therapy. all locations where medicines are stored. • Review and improve facilities for patients living with dementia and remove inconsistencies of care.

134 Ealing Hospital Quality Report 21/06/2016 This section is primarily information for the provider

Requirement notices R equir ement notic es

Action we have told the provider to take The table below shows the fundamental standards that were not being met. The provider must send CQC a report that says what action they are going to take to meet these fundamental standards.

135 Ealing Hospital Quality Report 21/06/2016